APPENDIX C SAMPLE LOG TO RECORD VALUE ADDED SERVICES (use is optional) w/o Contact min) Contact Staffing Meeting Provider:________________________ (<20 Observation Assistance Contact Agency Records Contact Staffing Date:___________________________ Visit Contact Mediation MD Medical Outside Home Classroom Review Brief LaCHIP Teacher/Administrator Family School Parent-Teacher Peer Interdisciplinary Student Name & SS# DOB # of times minutes
APPENDIX C SAMPLE LOG TO RECORD VALUE ADDED SERVICES (use is optional) Provider:________________________ Date:___________________________ LaCHIP Assistance Family Contact Teacher/Administrator Contact Classroom Observation Outside Agency Contact Review Records Home Visit Interdisciplinary Staffing w/o MD Brief Contact (<20 min) Medical Contact School Staffing Parent-Teacher Meeting Peer Mediation Student Name & SS# DOB # of times minutes