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. |
| MONTH _________________________ SITE _________________________ | ||||||||||||
| MONTH | (1) | (2) | (3) | (4) | (5) | (6) | (7) | (8) | (9) | (10) | (11) | (12) |
| NUMBER INACTIVATED THIS MONTH | NUMBER REACTIVATED THIS MONTH | NUMBER TERMINATED THIS MONTH | ||||||||||
| ACTIVE AT END OF LAST MONTH | SIGNED CARE PLAN BEFORE END OF LAST MONTH | NEWLY ACTIVE THIS MONTH | SIGNED CARE PLAN THIS MONTH | PRIOR TO CARE PLAN SIGN OFF | AFTER CARE PLAN SIGN OFF | PRIOR TO CARE PLAN SIGN OFF | AFTER CARE PLAN SIGN OFF | PRIOR TO CARE PLAN SIGN OFF | AFTER CARE PLAN SIGN OFF | CUMULATIVE NUMBER ACTIVE AT END OF MONTH | CUMULATIVE NUMBER ACTIVE AND SIGNED CARE PLAN AT END OF MONTH | |
| JUN82 | ||||||||||||
| JUL82 | ||||||||||||
| AUG82 | ||||||||||||
| SEP82 | ||||||||||||
| OCT82 | ||||||||||||
| NOV82 | ||||||||||||
| DEC82 | ||||||||||||
| JAN83 | ||||||||||||
| FEB83 | ||||||||||||
| MAR83 | ||||||||||||
| APR83 | ||||||||||||
| MAY83 | ||||||||||||
| JUN83 | ||||||||||||
| JUL83 | ||||||||||||
| AUG83 | ||||||||||||
| SEP83 | ||||||||||||
| OCT83 | ||||||||||||
| NOV83 | ||||||||||||
| DEC83 | ||||||||||||
| MONTH | (1) | (2) | (3) | (4) | (5) | (6) | (7) | (8) | (9) | (10) | (11) |
| NUMBER OF APPROPRIATES COMMUNICATED TO MPR | NUMBER OF INDVDULS REJECTED BECAUSE PREVIOUSLY ASSIGNED | NUMBER RANDOMIZED THIS MONTH (1)-(2) | NUMBER ASSIGNED TO TREATMENT GROUPS | # ASSGND TO CNTRL GROUPS | |||||||
| TOTAL | RSRCH SAMPLE | NON FOLLOW-UP | TOTAL | RSRCH SAMPLE | H-HOLD ASSGNMNT | ||||||
| RANDOM ASSGNMNT | H-HOLD ASSGNMENT | PRE/POST RANDOMIZATION | |||||||||
| FEB82 | |||||||||||
| MAR82 | |||||||||||
| APR82 | |||||||||||
| MAY82 | |||||||||||
| JUN82 | |||||||||||
| JUL82 | |||||||||||
| AUG82 | |||||||||||
| SEP82 | |||||||||||
| OCT82 | |||||||||||
| NOV82 | |||||||||||
| DEC82 | |||||||||||
| JAN83 | |||||||||||
| FEB83 | |||||||||||
| MAR83 | |||||||||||
| APR83 | |||||||||||
| MAY83 | |||||||||||
| JUN83 | |||||||||||
| CUM. | |||||||||||