Form Advocate Accountin Advocate Accountin Advocate Accounting of Tracing Activity

PCAP

OMB # 0930- XXXX
Expiration Date: xx/xx/xxxx
Form: 81

Advocate Accounting of
Tracing Activity on Missing Post-Exit Client
This form is to be completed and submitted at the end of each month, instead of the Monthly Update, until
the missing post-exit client is brought in for an Exit Interview.

➘

Date this form submitted: __

__/__ __/__ __

Advocate #:

Client's Program Exit Date (3 years past enrollment date): __

____

Client #:

__ __ __ __ __

__/__ __/__ __

What is the status of this missing client? Why hasn't she been brought in for an Exit Interview?

What have you done to try to contact this client? How frequently do you make attempts?

How often have you tried to contact her in the past month?

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)