Sample Record-keeping Worksheet

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Worksheet in PDF format

Use the spaces below to keep a record of the conversations you have with service agencies and others regarding your child.

Problem/Topic:

Name of person or agency you talked to:

Name of your contact person (may be same as above):

Date you called: _______________________________________________

Phone #: _____________________________________________________

Email address: ________________________________________________

Results of discussion: __________________________________________

Action taken (if any):

Person not helpful on this topic, but may be helpful regarding (list topics/areas/issues):

Next steps (Follow up needed):

NOTICE: NICHCY is going away, but its resources are not. Find hundreds of legacy NICHCY publications, as well as our training curriculum on IDEA 2004, in the Center for Parent Information and Resources' Library at http://www.parentcenterhub.org/resources. This website will remain available until September 30, 2014. After that date, web visitors will be automatically redirected to http://www.parentcenterhub.org.