GA Foods Call Attempt & Feedback Form
Please use this form to record your call attempt and provide relevant feedback.
Date
*
-
Month
-
Day
Year
Date
GA Client ID
*
RD Name
*
Attempt # (if known)
Please Select
1
2
3
4+
Outcome
*
Please Select
Nutrition counseling session completed
Reached on previous call attempts but session was not completed due to wrong timing, unable to reach again, etc.
Client is no longer eligible for nutrition counseling or this is a duplicated session
Contact was made with client and they rejected services
All 3 attempts have been made and no contact with the client was made
Agreed to Meals
Refused Meals
Unreachable - No Answer
Bad Phone Number
Bad Data - Wrong Number
Bad Data - Number Disconnected
Bad Data - Fast Busy Signal
Bad Data - Fax
Voicemail - Left Message
UTR - No Voicemail Available
Voicemail - Full Mailbox
UTR - Incoming Calls Restricted
UTR - Reached but Member in/returning to Facility/SNF/Hospice/Acute/IP
Client Deceased
Client in an Assisted Living Facility
Client Still in the Hospital
Client in Hospice
Ineligible for Program
2-month Follow-up Call
1-month Follow-up Call
Agreed to Nutritional Counseling
Positive feedback and notes from member (optional):
Questions/comments/concerns for VHP team (optional):
Submit
Should be Empty: