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Oregon Youth Challenge Program Post Residential Report Form
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* Indicates required question
Case Manager
*
Choose
Sasha.R.GREENBERG@omd.oregon.gov
David.R.SUTTERFIELD@omd.oregon.gov
Connie.MORGAN@omd.oregon.gov
Selena.CLEMENS@mil.state.or.us
Scott.H.LAWRENCE@omd.oregon.gov
Reporter Name
*
Your answer
Reporter Type
*
Mentor
Mentee / Cadet
Other
Reporter Email
*
Your answer
Cadet Name
*
Your answer
Cadet Email
Your answer
Class Number
*
64
65
66
Reporting Month
*
Choose
January
February
March
April
May
June
July
August
September
October
November
December
4 Contacts or 4 Hours
*
During the reporting period, did you have a minimum of 4 contacts, four hours of contact, or a combination of both?
Yes
No
Contact 1 Type
Choose
Email
Face to Face
Letter
Phone
Social Media
Texting
Contact 1 Date
MM
/
DD
/
YYYY
Contact 2 Type
Choose
Email
Face to Face
Letter
Phone
Social Media
Texting
Contact 2 Date
MM
/
DD
/
YYYY
Contact 3 Type
Choose
Email
Face to Face
Letter
Phone
Social Media
Texting
Contact 3 Date
MM
/
DD
/
YYYY
Contact 4 Type
Choose
Email
Face to Face
Letter
Phone
Social Media
Texting
Contact 4 Date
MM
/
DD
/
YYYY
Does the cadet have a placement?
*
Placements are School, Employment, Military, Miscellaneous/Volunteer.
Yes, they have a placement
No Placement
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