Child and Adult Care Food Program Household Contact Form Site/Provider Name: Name of Staff Member Conducting the Household Contact: Child/Children Names: Name Of Person Interviewed: Reason for Initiating Household Contact: Attempt #1 Attempt #2 Attempt #3 Date: Date: Date: Type of Contact: Type of Contact: Type of Contact: Contact: Yes No Contact: Yes No Contact: Yes No Initiate Secondary Contact: State circumstances for no contact: State circumstances for no contact: Yes No State circumstances for no contact and initiation of secondary contact: Information Obtained from Household Contact: Action Taken:
Child and Adult Care Food Program Household Contact Form Site/Provider Name: Name of Staff Member Conducting the Household Contact: Child/Children Names: Name Of Person Interviewed: Reason for Initiating Household Contact: Attempt #1 Date: Type of Contact: Contact: Yes No State circumstances for no contact: Attempt #2 Date: Type of Contact: Contact: Yes No State circumstances for no contact: Attempt #3 Date: Type of Contact: Contact: Yes No Initiate Secondary Contact: Yes No State circumstances for no contact and initiation of secondary contact: Information Obtained from Household Contact: Action Taken:
Household%20Contact%202017_08_02.docx