Program Summary Form
This form is to be completed by program leaders after each program/event.
Fields marked with an * are required.
Program Number/Name
*
Facility/Location
*
Any program deviations or changes?
*
Were any participants absent? Please note if the absence was expected or unexpected, and provide any comments.
Additional documentation being submitted due to incidents at the program:
Accident/Incident Form
Employee Injury
Behavior Report
Seizure Report
Were any staff absent or late? Only list unexpected absences or tardiness.
*
Were any participants picked up late?
*
Yes
No
Suggestions/Comments/Concerns
Submitted By (First/Last Name)
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: