Site Monthly Caseload Report

06/26/2012

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.                      
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