SAMPLE FORMS

Contact or Encounter Form

Form for Items Distributed

Form for Items Received

CONTACT OR ENCOUNTER FORM

Design a brief form, similar to the one shown here, to keep track of all contacts related to program activities between program personnel and people outside the program. Tailor the type of contact and services provided sections to the activities conducted by your program. For example, an enforcement program might have a list of reasons for stopping drivers or a list of types of sobriety checks. If a category labeled Other is used frequently, you need to add new categories to accommodate items that are being assigned to Other. Below is a general contact form that can be adapted for any program to prevent unintentional injury.

FORM FOR ITEMS DISTRIBUTED

A distribution form should be completed for each unit (i.e., person or household in the target population) to whom items (e.g., infant safety seats) were distributed. The purpose is to document the number of items distributed and the characteristics of the people who received the item(s). Below is a generic form that can be adapted to suit your program.

FORM FOR ITEMS RECEIVED

Keep track of all items given to you by members of the target population. An example of items received would be car safety seats returned to a loan program. The purpose is to document the number of items received and the characteristics of the people who hand in the items. Below is a generic form that can be adapted to suit your program.

This page last reviewed April 1, 2005.

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