Form Close Out Close Out CloseOut

OMB # 0930- XXXX
Expiration Date: xx/xx/xxxx
PCAP Client Module

Client Exit Close-out Form
Agency Name: ___________________________

Site Name: ______________________________

Client #: __ __ __ __ __ __

Date: __ __ / __ __ / __ __ __ __

1. Total number of months this client spent in PCAP (as of exit): __ __
2. a. Number of different advocates this client had over her time in the project: __
b. List all advocates this client had by name and advocate number: (Code 0 if no more)
Name

# Months

Advocate #

1) ________________________________

__ __

__ __ __

2) ________________________________

__ __

__ __ __

3) ________________________________

__ __

__ __ __

4) ________________________________

__ __

__ __ __

3. a. Did client ever move out of area, making it impossible to do home visitation or stay in close contact?
 Yes
 No
Where did she move? Beginning when? For how long was she out of the area? Describe:

b. For how many months was client out of contact with program? __ __
4. If there are any reasons that make this client unusual for purposes of analyzing data, please note below:

Advocate #: __ __ __

ADAI Sound Data Source—2/2/2007
http://adai.washington.edu/sounddatasource

Parent-Child Assistance Program (PCAP)
University of Washington

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB
control number for this project is 0930-xxxx. Public reporting burden for this collection of information is estimated to average 15 minutes per client per year, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance
Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland,20857.