Form 1 Program Director Client List

SCP Grantee Clients List

Please answer the following questions and fill in the requested information for each client. Return this form to JBS International, the research firm who is conducting the survey.

Today’s Date: ________________________________________________________________

Organization Name: ___________________________________________________________

Grant Number: _____________________________________________________

SCP Project Director Contact Information:

Name: ___________________________________________________

Telephone: _______________________________________________

E-mail: __________________________________________________

State where SCP program operates: _______________________________________________

City where SCP program operates:

1. _____________________________________

2. _____________________________________

3. _____________________________________

4. _____________________________________

Total number of clients served by your program (all sites/stations): ____________________________

Clients receiving independent living/companionship services
					Assistance (if applicable)
					Survey language needed, if other than English	Type of assistance needed, if applicable (reading/ writing only; surrogate)	Surrogate, if needed
Name of client	Date client began receiving SCP services	Check (X) if received services at least six months	Contact information for client	Salutation used for client (Ms./Mrs./Mr.)			Name	Relation-ship	Contact Information
Example: 112	2/12/12	X		Mrs.		surrogate	Jane Smith	daughter	Cell: (999) 999-9999
Example: 146	5/10/12	X	Home phone: (999) 999-999	Ms.	Spanish