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Dean Case Summary

Participant ID: *This question is required. This question requires a valid number format.

Please verify participant ID: *This question is required.

1. Total minutes of counseling

2. Level of engagement

Low	Medium	High
Low	Medium	High

3. Difficulty level to reach/complete appointments

Easy	Medium	High
Easy	Medium	High

4. Number of times physical address changed

5. Was participant referred to Quit Line?

What was the outcome from Quit Line report?

Please enter an 'other' value for this selection.

6. Support people received education?

# of Adults
# of Children

7. Support people referred to Texting Program (Enter # of Adults)

8. Number of support person(s) referred to Quit Line? (Enter #) This question requires a valid number format.

9. Outcome from Quit Line report for support people (Enter # for reach result type)

Unable to reach
Reached - NRT given
Reached - NRT not given. Reason:

10. Topics covered (all visits)?

11. Participant Case Summary