DATE:…………………………
AFRICAN AMERICAN
CONTACTS Level 1 Level 2 Level 3 Subtotals RISK CATEGORIES IDU Crack Alcohol Sex Partner Methadone Intra Nasal Cocaine Intra Nasal Heroin Marijuana Non Substance Users Pills Inhalants Subtotals AGE GROUPS Under 18 18+ - 35 35+ Subtotals SEXUAL ORIENT. MSM/WSW Bi-sexual Heterosexual Transsexual Transvestite Subtotals REFERRALS HCV Testing HIV Testing DAS/DSS Employment Vocational Training Medical Services TB Testing STD Priority Referrals Clothing Housing/Shelter Counseling Services Financial Services Food Pantry H.R./NEP'S Other Case Management Subtotals DRUG TREATMENT MMTP Long-Term Treatment (TC) Rehab. (21 - 28) Days Drug-free Program Detox (7 - 14) Days Alcohol Subtotals SUPPLIES Bleach Kits Condoms Dental Dams Individual Literature
…………………….. DAILY CONTACT SHEET
AFRICAN AMERICAN FEMALE HISPANIC MALE HISPANIC FEMALE WHITE MALE WHITE FEMALE
OUTREACH WKR.:…………………..
OTHER MALE OTHER FEMALE
TOTALS
MALE
* All comments should be written on back of the sheet. * Categories not applicable
* Check box if there are comments: No. of hours in field: ……………
Verified by: ……………………
Contact Initials: .…………….. Mass Distribution Bleach Condom
Grid #
Comments:
NATIONAL DEVELOPMENT AND RESEARCH INSTITUTES, INC.
BROOKLYN AOP STATISTICS - WEEK 1
WEEK OF: CONTACTS Level 1 Level 2 Level 3 Subtotals RISK CATEGORIES IDU Crack Alcohol Sex Partner Methadone Intra Nasal Cocaine Intra Nasal Heroin Marijuana Non Substance Users Pills Inhalants Subtotals AGE GROUPS Under 18 18+ - 35 35+ Subtotals SEXUAL ORIENTATION MSM/WSW Bi-sexual Heterosexual Transsexual Transvestite Subtotals REFERRALS HCV Testing HIV Testing DAS/DSS Employment Vocational Training Medical Services TB Testing STD Priority Referrals Clothing Housing/Shelter Counseling Services Financial Services Food Pantry NEP's/H.R. Other Case Management Subtotals DRUG TREATMENT MMTP Long-Term Treatment Rehab. Drug-free Detox Alcohol Subtotals SUPPLIES Bleach Kits Condoms Dental Dams Individual Literature Subtotals 0 0 0 0 0 0 0 0 AFRICAN AFRICAN HISPANIC HISPANIC AMERICAN AMERICAN MALE FEMALE MALE FEMALE WHITE MALE WHITE FEMALE OTHER MALE OTHER FEMALE TOTAL
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Prepared by: ____________________________
Verified by: ________________________
NATIONAL DEVELOPMENT AND RESEARCH INSTITUTES, INC.
MONDAY
WEEK OF: CONTACTS Level 1 Level 2 Level 3 Subtotals RISK CATEGORIES IDU Crack Alcohol Sex Partner Methadone Intra Nasal Cocaine Intra Nasal Heroin Marijuana Non Substance Users Pills Inhalants Subtotals AGE GROUPS Under 18 18+ - 35 35+ Subtotals SEXUAL ORIENTATION MSM/WSW Bi-sexual Heterosexual Transsexual Transvestite Subtotals REFERRALS HCV Testing HIV Testing DAS/DSS Employment Vocational Training Medical Services TB Testing STD Priority Referrals Clothing Housing/Shelter Counseling Services Financial Services Food Pantry NEP's/H.R. Other Case Management Subtotals DRUG TREATMENT MMTP Long-Term Treatment Rehab. Drug-free Detox Alcohol Subtotals SUPPLIES Bleach Kits Condoms Dental Dams Individual Literature Subtotals 0 0 0 0 0 0 0 0 AFRICAN AFRICAN HISPANIC HISPANIC AMERICAN AMERICAN MALE FEMALE MALE FEMALE WHITE MALE WHITE FEMALE OTHER MALE OTHER FEMALE TOTAL
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
NATIONAL DEVELOPMENT AND RESEARCH INSTITUTES, INC.
BROOKLYN AOP STATISTICS - MONTHLY
WEEK OF: CONTACTS Level 1 Level 2 Level 3 Subtotals RISK CATEGORIES IDU Crack Alcohol Sex Partner Methadone Intra Nasal Cocaine Intra Nasal Heroin Marijuana Non Substance Users Pills Inhalants Subtotals AGE GROUPS Under 18 18+ - 35 35+ Subtotals SEXUAL ORIENTATION MSM/WSW Bi-sexual Heterosexual Transsexual Transvestite Subtotals REFERRALS HCV Testing HIV Testing DAS/DSS Employment Vocational Training Medical Services TB Testing STD Priority Referrals Clothing Housing/Shelter Counseling Services Financial Services Food Pantry NEP's/H.R. Other Case Management Subtotals DRUG TREATMENT MMTP Long-Term Treatment Rehab. Drug-free Detox Alcohol Subtotals SUPPLIES Bleach Kits Condoms Dental Dams Individual Literature Subtotals 0 0 0 0 0 0 0 0 AFRICAN AFRICAN HISPANIC HISPANIC AMERICAN AMERICAN MALE FEMALE MALE FEMALE WHITE MALE WHITE FEMALE OTHER MALE OTHER FEMALE TOTAL
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Prepared by: _______________
Verified by: _____________
NATIONAL DEVELOPMENT AND RESEARCH INSTITUTES, INC.
BROOKLYN AOP MONTHLY REFERRAL LOG
REFERRED BY
DATE
NAME OF CLIENT
PLACE REFERRED TO
Long Term Drug-free Alcohol Rehab. MMTP Detox
M
F
M
F
M
F
M
F
M
F
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Total Drug Referrals = 0 0 0 0 0 0 0 0
*
KEPT Y = Yes NS = No Show NC = Program would not confirm UTC = Unable to confirm
TOTAL YES =
TOTAL WOULD NOT CONFIRM =
TOTAL NO SHOW =
TOTAL UNABLE TO CONFIRM =
Page 6 of 13
KEPT
AFRICAN AMERICAN
HISPANIC
WHITE
OTHER
SUBTOTAL
CONTACT PERSON
NATIONAL DEVELOPMENT AND RESEARCH INSTITUTES, INC.
BROOKLYN AOP MONTHLY REFERRAL LOG
REFERRED BY
DATE
NAME OF CLIENT
PLACE REFERRED TO
Long Term Drug-free Alcohol Rehab. MMTP Detox
M
F
M
F
M
F
M
F
M
F
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Total Drug Referrals = 0 0 0 0 0 0 0 0
*
KEPT Y = Yes NS = No Show NC = Program would not confirm UTC = Unable to confirm
TOTAL YES =
TOTAL WOULD NOT CONFIRM =
TOTAL NO SHOW =
TOTAL UNABLE TO CONFIRM =
Page 7 of 13
KEPT
AFRICAN AMERICAN
HISPANIC
WHITE
OTHER
SUBTOTAL
CONTACT PERSON
BROOKLYN AOP ONE TO ONE DISTRIBUTION
Grid 1 Bushwick
Date Bleach Condoms Dental Dams Literature Individual Sanitary Napkins Anti-bio Cream Toilet Paper Hygiene Kits Alcohol Preps Slippery Stuff
Totals Date
0 Bleach
0 Condoms
0 Dental Dams
0 Literature Individual
0 Sanitary Napkins
0
0 Toilet Paper
0 Hygiene Kits
0 Alcohol Preps
0 Slippery Stuff
Grid 1 Bushwick
Anti-bio Cream
Totals
0
0
0
0
0
0
0
0
0
0
8
BROOKLYN AOP MASS DISTRIBUTION
Names 1 Date Bleach Condom Bleach 2 Condom Bleach 3 Condom Bleach 4 Condom Bleach 5 Condom Bleach 6 Condom
Totals
0
0
0
0
0
0
0
0
0
0
0
0
Condom=
0
Bleach =
0
National Development and Research Institutes, Inc. Outreach Field Hours BROOKLYN AOP
DATE REASONS FOR SUSPENSION PARTICIPANTS # HRS. WORKED PER WORKER TOTAL HRS.
Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Worker(s) Total Monthly Field Hours =
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
NATIONAL DEVELOPMENT AND RESEARCH INSTITUTES, INC.
BOROUGH OFFICE: LINE ITEMS
(1) Gal. Generic Bleach Bottles (water) Bottles (bleach) Caps (white) Caps (black) Cookers Kits Assembled Bleach Pre-packed Bleach Pre-assembled Hygiene Condoms X-Tra Strength, SK-70 X-Tra Strength, N-9 Non Lube (brown) Novelty Condoms Miscellaneous Dental Dams Lit. Individual Sanitary Napkins Anti-biotic Cream Toilet Paper Alcohol Preps Disposable Toothbrushes Slippery Stuff Cotton Balls
BROOKLYN
NUMBER OF CASES MONTHLY OPENING BALANCE RECEIVED NUMBER TOTAL CASES PIECES
INVENTORY
TOTAL
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 TRANSFER NUMBER TOTAL CASES PIECES TOTAL PCS. DISTRIBUTED VIA OUTREACH
TOTAL
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
MONTHLY CLOSING BALANCE 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Bags Merchant Paper Bags Drawstring Bags Ziplock "3x3" Ziplock "6x6"
Generic Blch. - 6/1 gal. per case Water Bottles - 1,100 per case Bleach Bottles - 1,100 per case White Caps - 5,200 per case Black Caps - 2,000 per case Cookers - 4,600 per case Pre-packed Bleach Kits - 100 pcs. per case Hygiene Kits - 100 pcs. per case X-Tra Strength, SK-70 - 1,000 pcs per case X-Tra Strength, N-9 - 1,000 pcs per case NonLube (brown) - 1,000 pcs. per case Novelty Condoms - 50 pcs. per case
Alcohol Preps - 8,000 pcs. per case Sanitary Napkins - 24 pcs. per pack M. Bags - 1,000 per sleeve Anti-biotic Cream - 144 pcs. per case Toilet Paper - 96 rolls per box D. String - 100 per case Cotton Balls - 2 bags - 2,000 per bag Slippery Stuff - 500 pcs. per case Ziplock - 3x3 - 1,000 per case Dental Dams - 20 bxs. per case Ziplock - 6x6 - 1,000 per case Literature -184 pcs. Note: During inventory the amount of units on hand and pieces contained in each unit should be recorded Prepared by:__________ Verified by:_________
National Development and Research Institutes, Inc.
VEHICLE CHECK LIST BROOKLYN AOP
Time: p.m. Gas: Tank Last Used By: Mileage: Brake: Horn: Headlights: Left: Right: Tail Lights: Left: Right: Body Damage: Fender Left Front: Fender Right Front: Doors: Fender Left Rear: Fender Right Rear: Back:
Comments:
Date: Vehicle Make: Ford Winstar - 03
Tires: Spare: Windows: Seat: Battery: Air Cond.: Flashlight: Camera & Film: First Aid Kit.: Inspection exp. Date: Regis. Exp. Date:
Fluid Information: Window Fluid: Transmission: Power Steering: Motor Oil:
Verified by:
* Please attach copies of ALL accident reports that may have occurred during the month.
NATIONAL DEVELOPMENT RESEARCH & INSTITUTES, INC.
BROOKLYN AOP
VEHICLE MILEAGE LOG
DATES DESTINATION
BUSINESS PURPOSE
MILEAGE READING
BEG. OF T RI P END OF T RI P
BUSINESS MILES 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NAME OF DRIVER(S)
Total Mileage =
0
Verified By: