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United We Guide Call Log
Fiscal Year
2013-2014
2014-2015
2015-2016
2016-2017
2017-2018
2018-2019
2019-2020
This information was obtained by:
Phone
Email
Walk-in
Outreach Event
Referral
Other
Full Name of caller:
*
First Name
Last Name
Are you calling for yourself or on behalf of someone else?
Yes
No
Other
Caller's relationship to Individual:
Please Select
Mother
Father
Child
Grandparent
Caregiver/Attendant/Nurse
Advocate/Case Mgr.
Address of person needing services (may not necessarily be the caller):
Street Address
Street Address Line 2
City
State
Postal Zip Code
County:
Please Select
Alachua
Baker
Bay
Bradford
Brevard
Broward
Calhoun
Charlotte
Citrus
Clay
Collier
Columbia
Dixie
DeSoto
Duval
Escambia
Flagler
Franklin
Gadsden
Gilchrist
Glades
Gulf
Hamilton
Hardee
Hendry
Hernando
Highlands
Hillsborough
Holmes
Indian River
Jackson
Jefferson
Lafayette
Lake
Lee
Leon
Levy
Liberty
Madison
Manatee
Marion
Martin
Miami – Dade
Monroe
Nassau
Okaloosa
Okeechobee
Orange
Osceola
Palm Beach
Pasco
Pinellas
Polk
Putnam
St. Johns
St. Lucie
Santa Rosa
Sarasota
Seminole
Sumter
Suwannee
Taylor
Union
Volusia
Wakulla
Walton
Washington
E-mail:
Skip if not supplied
Contact Phone Number
-
Area Code
Phone Number
Age of person seeking services:
20 or younger
21 -35
36-45
46-64
65 and older
Other
Is this client currently:
Licensed and driving
Licensed and not driving
Unlicensed
Is the client a Veteran?
Yes
No
Immediate Relative of a Veteran (Mother/Father/Child/Grandchild)
Other
Where is the client going?
Medical Appointment/ Pharmacy
Employment
Education/Training
Nutritional
Other Life Sustaining
Recreational Trip
Adult Day Care
Is this a Re-occurring Trip?
Yes
No
Unknown
Trip begin date & time:
-
Month
-
Day
Year
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1
2
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4
5
6
7
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10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Trip end date & time:
-
Month
-
Day
Year
Date Picker Icon
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
What type of service does the client need information on?
*
Automobile/Driving Resources
Driver Assessment/Training
Paratransit Service (Door-to-door/Destination to destination,Etc.)
Public Transit
Resident based transportation program (Assisted Living
Facility/Senior Living Facility/Group Home/Nursing Home)
Non-Emergency Medicaid Transportation
Volunteer Driver Program
Ride sharing program/Van Pool/Car Pool
Other
Does the client have special needs, require assistance or a mobility aide?
Braces
Cane/Walker
Caregiver/Escort/Attendant
Crutches
Manual Wheelchair
Motorized wheelchair
Respirator
Service Animal
Is the destination located:
In County
Out of County
Out of State
Other
How did the caller hear about us?
*
Local Agency
Guidebook
Family / Friend
Newspaper Ad
Website
Phonebook
Walk-in
Referral
Other
Would you like a guidebook to learn about transportation options?
*
Yes
No
Information will be mailed
Information will be emailed
Would you be willing to participate in a follow up survey?
*
Yes
No
Any language preference?
*
Please Select
English
Spanish
French/Creole
Other
Thank the caller and inform them to, "Please call us back if you need further assistance or if the agency I have referred you to was unable to assist with your transportation needs. If you have internet, you can access the Safe and Mobile Seniors Website at www.safeandmobileseniors.com for more information. Thank you for calling! "
Mobility Manager taking this call:
Andrea Rosser
Katie Arnold
Rashaunda Grant
Polk County Mobility Manager
Other
Date and Time of call:
-
Month
-
Day
Year
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Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Did you feel you were able to provide pertinent information to the caller?
Yes
No
Partially
Additional Notes:
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Follow-up Contact:
Follow-up Contact:
-
Month
-
Day
Year
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10
11
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Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: