YEAR OF REPORT CALENDAR USTF PROJECT CODE: REPORTING QUARTER: (CHECK ONE): NAME OF AGENCY: JULY 1 TO SEPTEMBER 30 1 NAME OF PROGRAM: OCTOBER 1 TO DECEMBER 31 2 PERSON COMPLETING FORM / PHONE #: JANUARY 1 TO MARCH 31 3 DATE SUBMITTED: APRIL 1 TO JUNE 30 4 CHECK AGENCY REPORTING 1 2 3 4 QUARTER: CASELOAD 1. 2. 3. 4. 5. 6. Beginning New Transfers Transfers Terminations Ending Caseload Enrollees to In to From From Program Caseload (First Day Program Program Program Element (Last Day of of Qtr.) Element Element Element During Qtr. Qtr.) During Qtr. During Qtr. During Qtr. VOLUME INDICATORS (PROGRAM OUTPUTS) Month 1 Month 2 Month 3 Quarter Total Assessment Completed, Not Admitted to EISS: Total Episodes of Care Commenced During Month: Enrollment on Last Day of Month: Month 1 Month 2 Month 3 Quarter Total a. Program Assessment (PA) /Intake : (Auto-calculated total of 10b + 10c) Number of PA contact hours: On-site Number of PA contact hours: Off-site a. Psychiatric Evaluation (PsyE) Sessions: (Auto-calculated total of 11b + 11c) Month 1 Month 2 Month 3 Quarter Total Number of PsyE contact hours: On-site
USTF PROJECT CODE: CALENDAR YEAR OF REPORT REPORTING QUARTER: (CHECK ONE): NAME OF AGENCY: JULY 1 TO SEPTEMBER 30 1 NAME OF PROGRAM: OCTOBER 1 TO DECEMBER 31 2 PERSON COMPLETING FORM / PHONE #: JANUARY 1 TO MARCH 31 3 DATE SUBMITTED: APRIL 1 TO JUNE 30 4 CHECK AGENCY REPORTING QUARTER: 1 2 3 4 CASELOAD 1. 2. 3. 4. 5. 6. Beginning Caseload (First Day of Qtr.) New Enrollees to Program Element During Qtr. Transfers In to Program Element During Qtr. Transfers From Program Element During Qtr. Terminations From Program Element During Qtr. Ending Caseload (Last Day of Qtr.) VOLUME INDICATORS (PROGRAM OUTPUTS) Month 1 Month 2 Month 3 Quarter Total Assessment Completed, Not Admitted to EISS: Total Episodes of Care Commenced During Month: Enrollment on Last Day of Month: Month 1 Month 2 Month 3 Quarter Total a. Program Assessment (PA) /Intake : (Auto-calculated total of 10b + 10c) Number of On-site PA contact hours: Number of Off-site PA contact hours: a. Psychiatric Evaluation (PsyE) Sessions: (Auto-calculated total of 11b + 11c) Month 1 Month 2 Month 3 Quarter Total Number of On-site PsyE contact hours:
QCMR_14_EISS.docx