Archived: Making Information Work for You - Toolkit

SAMPLE ENCOUNTER LOG Site ID: ___________________________ Form completed by: _________________________ Loc.#: _____________________________ Contact at: ( ) ____________________
_____________________________________ (Title of Collaborative)
ENCOUNTER: Record each service delivered on a separate line. Note duplicate information with vertical arrows in columns.
Client Name	Client ID #	Birth date (M/D/Y)	Gend. (circle) M F	Ethnic. (code)	Date of encounter (M/D/Y)	Referred by (code)	Location (code)	Service need (code)	Status (codes)	External referral info./comments
			1 2
			1 2
			1 2
			1 2
			1 2
			1 2
			1 2
			1 2
			1 2
			1 2

Ethnicity = 1) American Indian, 2) Asian, 3) African American, 4) Hispanic, 5) Pacific Islander, 6) White Referred by = 1) self, 2) family/friend, 3) On-site service provider, 4) school staff, 5) off-site service provider. Location = 1) school campus, 2) off-campus center, 3) client's home, 4) telephone, 5) other (specify) Status = 1) service delivered, 2) awaiting service, 3) service not available, 4) client refused service, 5) external referral made (note agency in comments column).

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