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Client Contact Log

Mathematica Policy Research, Inc.

This instrument was developed for the National Long-Term Care Channeling Demonstration. This project was conducted by Mathematica Policy Research, Inc. under contract #HHS-100-80-0157 and Temple University under contract #HHS-100-80-0133 for the Department of Health and Human Services (HHS) Office of Social Services Policy (now Office of Disability, Aging and Long-Term Care Policy), as well as additional funding from the HHS Health Care Financing Administration (now Centers for Medicare and Medicaid Services) and HHS Administration on Aging. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The DALTCP Project Officer was Robert Clark.

NOTE: This is a recreation of this form. See the PDF version for a scanned version of the actual form.

 

MPRI 737
OMB # 0990-0080
Expires 9/84

CLIENT CONTACT LOG

 

SITE:  [_____]_____]   DATE OF RANDOM ASSIGNMENT  [_____]_____]  [_____]_____]  [_____]_____]   FOR MONTH OF _________________________, 19 [_____]_____]  

 

CLIENT NAME:   MPR CLIENT ID NUMBER:  [_____]_____]  [_____]_____]_____]_____]_____]  [_____]_____]  
Any Contacts During Month?   MODE:   CONTACT WITH:   CONTACT RELATED TO:    
YES   1   1. Telephone 1. Client 1. Baseline Assessment  
NO 2 2. In-Person, Home 2. Collateral 2. Specialized Assessment    
  3. In-Person, Office 3. Formal Provider 3. Initial Care-Planning  
  4. In-Person, Elsewhere   4. Informal Provider   4. Ongoing Care-Planning    
  5. Mail 5. Other 5. Arranging/Monitoring  
  6. Other   6. Reassessment  
      7. Other  
DATE
  [MONTH/DAY]  		 EMPLOYEE ID CIRCLE ONE CIRCLE ALL
THAT APPLY		 CIRCLE ONE TIME
SPENT
  [MINUTES]  		   COMMENTS  
[_____]_____]_____]_____] [_____]_____]_____]_____] 1  2  3  4  5  6 1  2  3  4  5 1  2  3  4  5  6  7    
[_____]_____]_____]_____] [_____]_____]_____]_____] 1  2  3  4  5  6 1  2  3  4  5 1  2  3  4  5  6  7    
[_____]_____]_____]_____] [_____]_____]_____]_____] 1  2  3  4  5  6 1  2  3  4  5 1  2  3  4  5  6  7    
[_____]_____]_____]_____] [_____]_____]_____]_____] 1  2  3  4  5  6 1  2  3  4  5 1  2  3  4  5  6  7    
[_____]_____]_____]_____] [_____]_____]_____]_____] 1  2  3  4  5  6 1  2  3  4  5 1  2  3  4  5  6  7    
[_____]_____]_____]_____] [_____]_____]_____]_____] 1  2  3  4  5  6 1  2  3  4  5 1  2  3  4  5  6  7    
[_____]_____]_____]_____] [_____]_____]_____]_____] 1  2  3  4  5  6 1  2  3  4  5 1  2  3  4  5  6  7    
[_____]_____]_____]_____] [_____]_____]_____]_____] 1  2  3  4  5  6 1  2  3  4  5 1  2  3  4  5  6  7    
[_____]_____]_____]_____] [_____]_____]_____]_____] 1  2  3  4  5  6 1  2  3  4  5 1  2  3  4  5  6  7    
[_____]_____]_____]_____] [_____]_____]_____]_____] 1  2  3  4  5  6 1  2  3  4  5 1  2  3  4  5  6  7    
[_____]_____]_____]_____] [_____]_____]_____]_____] 1  2  3  4  5  6 1  2  3  4  5 1  2  3  4  5  6  7    
Files
ClConLog_0.pdf (pdf, 314.34 KB)