Health Support Center
Member Monthly Report Form

These numbers reflect the activities of your organization during the reporting month. If more than one person reports this information, contact numbers and hours may be reported together (i.e. one form for two or more people) or individually (i.e. one form per person).

Member Organization:
Person Submitting Report:
Month and Year:
Number of Contacts:
Hours at HSC facilities:
Hours elsewhere:

Total Hours:
Significant Outcomes (optional)*:

* This information is used to document your organization's contributions to the community for funding purposes (i.e. United Way funding, HSC's Annual Report, etc.).


Examples of Contacts and Hours

  • Answering and returning calls; follow-up calls
  • Board meetings, committee meetings--(include planning and preparation times, drivinghome)
  • Support group meetings--(record number in attendance; include planning and preparation time, driving time.
  • Information fairs, booths, or tables--(record number of contacts)
 
     

Thank you for your report.