What to know
Please note, some of the examples in the Appendices may be outdated and may have changed. Those changes may not be reflected in this document.
Example #1: Courtesy of Colorado Bureau of Public Health
| Partner # | Email Date | Website Name | Partner’s Email | Email Script # | AM Logon Time | PM Logon Time | Notes/Outcome of Activity | Disease Verification (3rd Email) | Closure Code |
|---|---|---|---|---|---|---|---|---|---|
Your Name:
DIS # & State:
Initiation Date:
OP Id # and Disease:
| Date | Website | Log In Time | Log Out Time | Purpose | Staff/Sups Initials |
|---|---|---|---|---|---|
Example #2: Courtesy of Arkansas Department of Health
| Field Record # | Date Recd P1 to: | Screen Name/ Email Address | Website | Dis No. | Attempt and Outcome #1 | Attempt and Outcome #2 | Attempt and Outcome #3 | Dispo/Date | SN DB | Notes |
|---|---|---|---|---|---|---|---|---|---|---|
Month: __________________ Year: __________________