Case Notes and Activity Record
Please fill in the form below to describe the activities that you have completed. If you completed multiple activities with a family or individual, complete a separate form for each activity. Thank you for supporting refugees! - CWS Jersey City
Who were you helping?
Your answer
What day did you help them?
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/
DD
/
YYYY
What was the need or the problem you were trying to address?
Examples: Harry had an appointment and did not know how to get there; Ron needed someone to accompany him to apply for his Social Security Card; Ginny wanted to open a bank account.
Your answer
What action did you take, or what activity did you complete?
Examples: I showed Harry how to take the bus to the clinic and how to check-in; I accompanied Ron to the Social Security office and helped him with the application; I helped Ginny open a new bank account at First Bank.
Your answer
What is the plan after this activity? What will happen next?
Examples: Harry has a follow-up appointment but says he will take the bus on his own; Ron's Social Security card will arrive in the mail in four weeks; Ginny wants someone to show her how to write a check.
Your answer
Is there documentation or paperwork that resulted from this activity?
This could include an appointment reminder slip, a receipt of service, or contact information.
What is your name?
Your answer
If we have follow-up questions for you, how should we contact you?
Your answer
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