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Weekly Tally Sheet
Brief Educational and Supportive Services Not Elsewhere Included
Provider Name
Provider Number
OMB NO. 0930-0270
Expiration Date 09/30/2018
County or Parish
Employee IDWeek beginning mm/dd/yyyy
NUMBER OF CONTACTS OR NUMBERS DISTRIBUTED
SUN. MON. TUES. WED. THURS. FRI. SAT. TOTAL
In-person brief educational or
supportive contact
Telephone contact by crisis
counselor
Email contact
Material handed to people
Material mailed to people's
homes and/or left at a
person's unattended home
Material left in public places
Community networking and
coalition building
Note: If the number is zero, the field may be left blank.
TYPE OF CONTACT
PROJECT #
Date of ReviewSignatureReviewer Name
Hotline/helpline/lifeline contact
MATERIALS DISTRIBUTED
Mass media
Social networking messages
Do not include materials that are captured on individual/family or group encounter data collection forms.