Form K - Dx Int Lo Form K - Dx Int Lo Form K - Dx Int Lost Follow-up

OMB # 0930- XXXX

Expiration Date: xx/xx/xxxx

SAMHSA FASD Center for Excellence

Form K

Diagnosis and Intervention Programs

Client Participation Tracking Form (Eligibility through Follow-up)

This form is used in the SAMHSA FASD Center for Excellence Diagnosis and Intervention Programs to record information if a child is lost during intervention or at follow-up. To protect privacy, name and any other individually identifying information will not be collected.

Child ID: ______________

Date client contact lost: ______________

Reason child no longer accessible:

1. No longer at the current address

2. Parent/guardian refused to participate

3. Committed or incarcerated

4. No longer in target population (no longer in dependency court, no longer on probation, etc.)

5. Other reasons:___________

Date client contact resumed: ______________

Reason contact resumed:

1. Client who was no longer at the current address has been located

2. Parent/guardian consented to services

3. No longer committed or incarcerated

4. Client returned to target population

5. Other reasons:___________

6. Committed or incarcerated

7. No longer in target population (no longer in dependency court, no longer on probation, etc.)

8. Other reasons:___________

Additional Comments:

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 2 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.