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***Note: to update contact info, use the
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Information & Referral Tracking Form
Date of Contact
*
Staff
*
Choose 1:
*
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Individual
Organization
Name
Organization Name (if applicable):
Date of Birth (mm/dd/yyyy)
Gender
Person with Epilepsy
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Child 0-12
Teen 13-18
Young Adult 19-25
Adult 26-54
Senior 55+
Choose 1
*
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New Contact
Update Exisiting
Name of person with epilepsy (if different from above)
Birthdate of person with epilepsy
Relationship to Epilepsy
*
Self
Child with Epilepsy
Spouse / Partner has
Have a Parent (older)
Sibling / Non-immediate Family Member
Work with People with Seizures
Friend / Coworker
Unknown
Street Address
City
State / Province
Zip / Postal Code
Email
Phone
Phone Type
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Home
Mobile
Work
Total Number Served
*
Information & Referral:
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Call
Visit
I&R Topic
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Childcare
Devices
Discrimination/Legal Issues
Driving
Education
Employment
Follow Up
General EFMN Information
General Epilepsy Information
Housing
MA, MN Care, SSI/SSDI
Materials Request
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Other
Penry Travel Assistance Fund
Prescription Assistance
Referral
Transportation
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Subcategory
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Discovery Source
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Clinic
EFMN Staff
Media
Newsletter
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Other
Personal Referral
Website
Description
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Educational Trainings Tracking Form
Choose 1
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New Contact
Update Existing
Organization Name
*
Street Address
*
City
*
State / Province
*
Zip / Postal Code
*
Email
Office Phone
Type
*
FP (Fire / Police / Emergency Personnel)
S (District / Area)
S1 (Elementary)
S2 (Middle / Jr High)
S3 (High School)
S4 (College / Higher Ed)
SS (County Social Services and other non-profit organizations)
C (Clinics)
CS (Secondary Clinics)
H (Hospitals)
HHC (Home Health Care / Adult Day Services
SSO (Senior Serving Organization)
GH (Group Homes)
DC (Day Cares / HeadStart)
SC (Service Clubs)
COC (Chamber of Commerce)
O (Other)
Y (Youth Orgs)
Date
*
Staff
*
Total Number Served
*
Presentation Type
Presentations: Adult
Presentations: Senior and Seizures
Presentations: School Personnel
Student Presentation: 0-4
Student Presentation: K-3
Student Presentation: 4-7
Student Presentation: 8-12
Exhibits
Webinar
School Nurse
Additional Presentations (Type & Number Attended)
Male
Female
Contact Name