Form Client Lost Post E Client Lost Post E Client Lost Post Exit

PCAP

OMB # 0930- XXXX
Expiration Date: xx/xx/xxxx

Form: 80

Lost Post-Exit Client Form
Use this form when client is at least 6 months past her 3-year exit date in the program
and has not completed the ASI exit interview.

➘

Date this form submitted:

____________

Enrollment date: ____________

Dates of last:

Supervisor #:

Enr. site: __________

Face-to-face contact with client:

____

Adv #:

____

Exit date: ____________

____________

Client #:

Exit site: __________

Telephone contact:

Is location of this client known? .............................................................

YES

NO

Has client verbally refused to participate in exit interview?...............

YES

NO

Has this case been discussed at an Administrative Meeting? .........

YES

NO

________

____________

(For the following questions, use the back of the form if you need more space.)
1. If the client has refused, please explain circumstances.

2. If client has not refused, please describe what has been done to get client in for the exit interview.

3. If whereabouts are unknown, describe what has been done to locate client?

4. Are there any further steps to take at this time to locate client?

5. Any suggestions from the team?

Date Tracing was staffed with team:

IS CLIENT DECLARED LOST AT THIS TIME?

YES

____________

NO

Effective Date: ____________

If ‘NO’, continue tracing as Missing Post-Exit Client and do this form again in 6 months.

____________________________

_______________________________

Advocate signature

Supervisor signature

If client is declared lost post-exit, place client name on list of clients lost to follow-up. Move from active database to
graduated database. State Program Director must authorize move from missing to lost post-exit status.

Administrative Use Only

____________________________

_______________________________

Project Director signature

Date authorized
Project Director comments on back

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.
© 2005, Washington State Parent-Child Assistance Program (PCAP)