CAREGIVER SAMPLE LIST RESULTS by bti81428

VIEWS: 7 PAGES: 39

									                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
 1
             Care
         Recipient:

        Caregiver:
 2
             Care
         Recipient:

        Caregiver:
 3
             Care
         Recipient:

        Caregiver:
 4
             Care
         Recipient:

        Caregiver:
 5
             Care
         Recipient:

        Caregiver:
 6
             Care
         Recipient:

        Caregiver:
 7
             Care
         Recipient:

        Caregiver:
 8
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
 9
             Care
         Recipient:

        Caregiver:
10
             Care
         Recipient:

        Caregiver:
11
             Care
         Recipient:

        Caregiver:
12
             Care
         Recipient:

        Caregiver:
13
             Care
         Recipient:

        Caregiver:
14
             Care
         Recipient:

        Caregiver:
15
             Care
         Recipient:

        Caregiver:
16
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
17
             Care
         Recipient:

        Caregiver:
18
             Care
         Recipient:

        Caregiver:
19
             Care
         Recipient:

        Caregiver:
20
             Care
         Recipient:

        Caregiver:
21
             Care
         Recipient:

        Caregiver:
22
             Care
         Recipient:

        Caregiver:
23
             Care
         Recipient:

        Caregiver:
24
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
25
             Care
         Recipient:

        Caregiver:
26
             Care
         Recipient:

        Caregiver:
27
             Care
         Recipient:

        Caregiver:
28
             Care
         Recipient:

        Caregiver:
29
             Care
         Recipient:

        Caregiver:
30
             Care
         Recipient:

        Caregiver:
31
             Care
         Recipient:

        Caregiver:
32
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
33
             Care
         Recipient:

        Caregiver:
34
             Care
         Recipient:

        Caregiver:
35
             Care
         Recipient:

        Caregiver:
36
             Care
         Recipient:

        Caregiver:
37
             Care
         Recipient:

        Caregiver:
38
             Care
         Recipient:

        Caregiver:
39
             Care
         Recipient:

        Caregiver:
40
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
41
             Care
         Recipient:

        Caregiver:
42
             Care
         Recipient:

        Caregiver:
43
             Care
         Recipient:

        Caregiver:
44
             Care
         Recipient:

        Caregiver:
45
             Care
         Recipient:

        Caregiver:
46
             Care
         Recipient:

        Caregiver:
47
             Care
         Recipient:

        Caregiver:
48
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
49
             Care
         Recipient:

        Caregiver:
50
             Care
         Recipient:

        Caregiver:
51
             Care
         Recipient:

        Caregiver:
52
             Care
         Recipient:

        Caregiver:
53
             Care
         Recipient:

        Caregiver:
54
             Care
         Recipient:

        Caregiver:
55
             Care
         Recipient:

        Caregiver:
56
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
57
             Care
         Recipient:

        Caregiver:
58
             Care
         Recipient:

        Caregiver:
59
             Care
         Recipient:

        Caregiver:
60
             Care
         Recipient:

        Caregiver:
61
             Care
         Recipient:

        Caregiver:
62
             Care
         Recipient:

        Caregiver:
63
             Care
         Recipient:

        Caregiver:
64
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
65
             Care
         Recipient:

        Caregiver:
66
             Care
         Recipient:

        Caregiver:
67
             Care
         Recipient:

        Caregiver:
68
             Care
         Recipient:

        Caregiver:
69
             Care
         Recipient:

        Caregiver:
70
             Care
         Recipient:

        Caregiver:
71
             Care
         Recipient:

        Caregiver:
72
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
73
             Care
         Recipient:

        Caregiver:
74
             Care
         Recipient:

        Caregiver:
75
             Care
         Recipient:

        Caregiver:
76
             Care
         Recipient:

        Caregiver:
77
             Care
         Recipient:

        Caregiver:
78
             Care
         Recipient:

        Caregiver:
79
             Care
         Recipient:

        Caregiver:
80
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
81
             Care
         Recipient:

        Caregiver:
82
             Care
         Recipient:

        Caregiver:
83
             Care
         Recipient:

        Caregiver:
84
             Care
         Recipient:

        Caregiver:
85
             Care
         Recipient:

        Caregiver:
86
             Care
         Recipient:

        Caregiver:
87
             Care
         Recipient:

        Caregiver:
88
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
89
             Care
         Recipient:

        Caregiver:
90
             Care
         Recipient:

        Caregiver:
91
             Care
         Recipient:

        Caregiver:
92
             Care
         Recipient:

        Caregiver:
93
             Care
         Recipient:

        Caregiver:
94
             Care
         Recipient:

        Caregiver:
95
             Care
         Recipient:

        Caregiver:
96
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
97
             Care
         Recipient:

        Caregiver:
98
             Care
         Recipient:

        Caregiver:
99
             Care
         Recipient:

        Caregiver:
100
             Care
         Recipient:

        Caregiver:
101
             Care
         Recipient:

        Caregiver:
102
             Care
         Recipient:

        Caregiver:
103
             Care
         Recipient:

        Caregiver:
104
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
105
             Care
         Recipient:

        Caregiver:
106
             Care
         Recipient:

        Caregiver:
107
             Care
         Recipient:

        Caregiver:
108
             Care
         Recipient:

        Caregiver:
109
             Care
         Recipient:

        Caregiver:
110
             Care
         Recipient:

        Caregiver:
111
             Care
         Recipient:

        Caregiver:
112
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
113
             Care
         Recipient:

        Caregiver:
114
             Care
         Recipient:

        Caregiver:
115
             Care
         Recipient:

        Caregiver:
116
             Care
         Recipient:

        Caregiver:
117
             Care
         Recipient:

        Caregiver:
118
             Care
         Recipient:

        Caregiver:
119
             Care
         Recipient:

        Caregiver:
120
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
121
             Care
         Recipient:

        Caregiver:
122
             Care
         Recipient:

        Caregiver:
123
             Care
         Recipient:

        Caregiver:
124
             Care
         Recipient:

        Caregiver:
125
             Care
         Recipient:

        Caregiver:
126
             Care
         Recipient:

        Caregiver:
127
             Care
         Recipient:

        Caregiver:
128
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
129
             Care
         Recipient:

        Caregiver:
130
             Care
         Recipient:

        Caregiver:
131
             Care
         Recipient:

        Caregiver:
132
             Care
         Recipient:

        Caregiver:
133
             Care
         Recipient:

        Caregiver:
134
             Care
         Recipient:

        Caregiver:
135
             Care
         Recipient:

        Caregiver:
136
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
137
             Care
         Recipient:

        Caregiver:
138
             Care
         Recipient:

        Caregiver:
139
             Care
         Recipient:

        Caregiver:
140
             Care
         Recipient:

        Caregiver:
141
             Care
         Recipient:

        Caregiver:
142
             Care
         Recipient:

        Caregiver:
143
             Care
         Recipient:

        Caregiver:
144
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
145
             Care
         Recipient:

        Caregiver:
146
             Care
         Recipient:

        Caregiver:
147
             Care
         Recipient:

        Caregiver:
148
             Care
         Recipient:

        Caregiver:
149
             Care
         Recipient:

        Caregiver:
150
             Care
         Recipient:

        Caregiver:
151
             Care
         Recipient:

        Caregiver:
152
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
153
             Care
         Recipient:

        Caregiver:
154
             Care
         Recipient:

        Caregiver:
155
             Care
         Recipient:

        Caregiver:
156
             Care
         Recipient:

        Caregiver:
157
             Care
         Recipient:

        Caregiver:
158
             Care
         Recipient:

        Caregiver:
159
             Care
         Recipient:

        Caregiver:
160
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
161
             Care
         Recipient:

        Caregiver:
162
             Care
         Recipient:

        Caregiver:
163
             Care
         Recipient:

        Caregiver:
164
             Care
         Recipient:

        Caregiver:
165
             Care
         Recipient:

        Caregiver:
166
             Care
         Recipient:

        Caregiver:
167
             Care
         Recipient:

        Caregiver:
168
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
169
             Care
         Recipient:

        Caregiver:
170
             Care
         Recipient:

        Caregiver:
171
             Care
         Recipient:

        Caregiver:
172
             Care
         Recipient:

        Caregiver:
173
             Care
         Recipient:

        Caregiver:
174
             Care
         Recipient:

        Caregiver:
175
             Care
         Recipient:

        Caregiver:
176
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
177
             Care
         Recipient:

        Caregiver:
178
             Care
         Recipient:

        Caregiver:
179
             Care
         Recipient:

        Caregiver:
180
             Care
         Recipient:

        Caregiver:
181
             Care
         Recipient:

        Caregiver:
182
             Care
         Recipient:

        Caregiver:
183
             Care
         Recipient:

        Caregiver:
184
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
185
             Care
         Recipient:

        Caregiver:
186
             Care
         Recipient:

        Caregiver:
187
             Care
         Recipient:

        Caregiver:
188
             Care
         Recipient:

        Caregiver:
189
             Care
         Recipient:

        Caregiver:
190
             Care
         Recipient:

        Caregiver:
191
             Care
         Recipient:

        Caregiver:
192
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
193
             Care
         Recipient:

        Caregiver:
194
             Care
         Recipient:

        Caregiver:
195
             Care
         Recipient:

        Caregiver:
196
             Care
         Recipient:

        Caregiver:
197
             Care
         Recipient:

        Caregiver:
198
             Care
         Recipient:

        Caregiver:
199
             Care
         Recipient:

        Caregiver:
200
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
201
             Care
         Recipient:

        Caregiver:
202
             Care
         Recipient:

        Caregiver:
203
             Care
         Recipient:

        Caregiver:
204
             Care
         Recipient:

        Caregiver:
205
             Care
         Recipient:

        Caregiver:
206
             Care
         Recipient:

        Caregiver:
207
             Care
         Recipient:

        Caregiver:
208
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
209
             Care
         Recipient:

        Caregiver:
210
             Care
         Recipient:

        Caregiver:
211
             Care
         Recipient:

        Caregiver:
212
             Care
         Recipient:

        Caregiver:
213
             Care
         Recipient:

        Caregiver:
214
             Care
         Recipient:

        Caregiver:
215
             Care
         Recipient:

        Caregiver:
216
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
217
             Care
         Recipient:

        Caregiver:
218
             Care
         Recipient:

        Caregiver:
219
             Care
         Recipient:

        Caregiver:
220
             Care
         Recipient:

        Caregiver:
221
             Care
         Recipient:

        Caregiver:
222
             Care
         Recipient:

        Caregiver:
223
             Care
         Recipient:

        Caregiver:
224
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
225
             Care
         Recipient:

        Caregiver:
226
             Care
         Recipient:

        Caregiver:
227
             Care
         Recipient:

        Caregiver:
228
             Care
         Recipient:

        Caregiver:
229
             Care
         Recipient:

        Caregiver:
230
             Care
         Recipient:

        Caregiver:
231
             Care
         Recipient:

        Caregiver:
232
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
233
             Care
         Recipient:

        Caregiver:
234
             Care
         Recipient:

        Caregiver:
235
             Care
         Recipient:

        Caregiver:
236
             Care
         Recipient:

        Caregiver:
237
             Care
         Recipient:

        Caregiver:
238
             Care
         Recipient:

        Caregiver:
239
             Care
         Recipient:

        Caregiver:
240
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
241
             Care
         Recipient:

        Caregiver:
242
             Care
         Recipient:

        Caregiver:
243
             Care
         Recipient:

        Caregiver:
244
             Care
         Recipient:

        Caregiver:
245
             Care
         Recipient:

        Caregiver:
246
             Care
         Recipient:

        Caregiver:
247
             Care
         Recipient:

        Caregiver:
248
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
249
             Care
         Recipient:

        Caregiver:
250
             Care
         Recipient:

        Caregiver:
251
             Care
         Recipient:

        Caregiver:
252
             Care
         Recipient:

        Caregiver:
253
             Care
         Recipient:

        Caregiver:
254
             Care
         Recipient:

        Caregiver:
255
             Care
         Recipient:

        Caregiver:
256
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
257
             Care
         Recipient:

        Caregiver:
258
             Care
         Recipient:

        Caregiver:
259
             Care
         Recipient:

        Caregiver:
260
             Care
         Recipient:

        Caregiver:
261
             Care
         Recipient:

        Caregiver:
262
             Care
         Recipient:

        Caregiver:
263
             Care
         Recipient:

        Caregiver:
264
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
265
             Care
         Recipient:

        Caregiver:
266
             Care
         Recipient:

        Caregiver:
267
             Care
         Recipient:

        Caregiver:
268
             Care
         Recipient:

        Caregiver:
269
             Care
         Recipient:

        Caregiver:
270
             Care
         Recipient:

        Caregiver:
271
             Care
         Recipient:

        Caregiver:
272
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
273
             Care
         Recipient:

        Caregiver:
274
             Care
         Recipient:

        Caregiver:
275
             Care
         Recipient:

        Caregiver:
276
             Care
         Recipient:

        Caregiver:
277
             Care
         Recipient:

        Caregiver:
278
             Care
         Recipient:

        Caregiver:
279
             Care
         Recipient:

        Caregiver:
280
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
281
             Care
         Recipient:

        Caregiver:
282
             Care
         Recipient:

        Caregiver:
283
             Care
         Recipient:

        Caregiver:
284
             Care
         Recipient:

        Caregiver:
285
             Care
         Recipient:

        Caregiver:
286
             Care
         Recipient:

        Caregiver:
287
             Care
         Recipient:

        Caregiver:
288
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
289
             Care
         Recipient:

        Caregiver:
290
             Care
         Recipient:

        Caregiver:
291
             Care
         Recipient:

        Caregiver:
292
             Care
         Recipient:

        Caregiver:
293
             Care
         Recipient:

        Caregiver:
294
             Care
         Recipient:

        Caregiver:
295
             Care
         Recipient:

        Caregiver:
296
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
297
             Care
         Recipient:

        Caregiver:
298
             Care
         Recipient:

        Caregiver:
299
             Care
         Recipient:

        Caregiver:
300
             Care
         Recipient:

        Caregiver:
301
             Care
         Recipient:

        Caregiver:
302
             Care
         Recipient:

        Caregiver:
303
             Care
         Recipient:

        Caregiver:
304
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver
                                                POMP 5
                        CAREGIVER SAMPLE LIST & RESULTS                                                          TELEPHONE INTERVIEW CALLER LOG

                                   FILL OUT BEFORE INTERVIEWING                                                  Date and Time of Attempts to Contact Caregiver
Row                                                                              Sex           Result
No.                     ID      Name                         Phone               M/F    Age    Code          1             2           3           4              5

        Caregiver:
305
             Care
         Recipient:

        Caregiver:
306
             Care
         Recipient:

        Caregiver:
307
             Care
         Recipient:

        Caregiver:
308
             Care
         Recipient:

        Caregiver:
309
             Care
         Recipient:

        Caregiver:
310
             Care
         Recipient:

        Caregiver:
311
             Care
         Recipient:

        Caregiver:
312
             Care
         Recipient:


      Result Codes: CO=Completed; PC= Partial; IN=Ineligible, provides no care; IE=Ineligible age; T1=Termination; T2=Termination; RF=Refused; NA=No answer;
      NL=Not able to locate; LH=Language; OT=Other; DR=Deceased Recipient; DC=Deceased Caregiver

								
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