Appendix D

Appendix D

ISIS Demonstration and Evaluation Contact Form

EVALUATION OF THE “INNOVATIVE STRATEGIES FOR

IMPROVING SELF-SUFFICIENCY” (ISIS) DEMONSTRATIONS

ABT ASSOCIATES

CONTACT FORM

CONTACT INFORMATION

ISIS Log Control Number:___________

Date Of This Contact: ______________________________

ISIS team member who had this contact:_______________________________

Person/Organization contacted:

Name/Title:____________________________________________________

Org./Agency:___________________________________________________

___________________________________________________

Address: ___________________________________________________

___________________________________________________

Phone: __________________________________________________

Email: ___________________________________________________

Policymaker  Assn. Rep.  Advocacy Rep  Program Practioner 

Researcher  Other____________

Purpose/Source of contact:  Followup after an earlier ISIS contact  Person contacted by ISIS

 Opportune meeting  Referred by______________________

 Q&A after ISIS presentation/meeting  Other source _____________________

 Person contacted ISIS

RECORD OF DISCUSSION

Summary of conversation and areas covered (attach sheet if necessary):

Note: Topics of particular interest that should be noted in the above summary include:

Experimental design issues Research/Eval. Reports/Findings

Priority strategies of interest to test Potential study programs/sites

Potential interest in partnering with ISIS Consider potential exploratory site visit

ACTION REQUIRED:

Follow up immediately:  ________________________________________________________________________

(Specify ISIS team/member who should make the contact and who to contact)

Follow up by specific date:  ________________________________________________________________________

(Specify ISIS team/member who should make the contact and who to contact)

Obtain documents noted:  ________________________________________________________________________

(Specify ISIS team/member who should make the contact and who to contact)

No followup at this time: 

Additional Notes: __________________________________________________________________________________