Public Health Survey Call Log Form
Log details of your outreach calls for the public health survey. Please complete all fields to ensure accurate record-keeping.
Caller Name
*
First Name
Last Name
Date and Time of Call
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Contact Method
*
Please Select
Phone
Video Call
Text Message
Email
Other
Person Contacted
*
Call Outcome
*
Completed Survey
Refused
No Answer
Call Back Later
Wrong Number
Other
Interest in Survey
*
Very Interested
Somewhat Interested
Not Interested
Not Applicable
Call Ease (How smoothly did the call go?)
*
Very Difficult
1
2
3
4
Very Easy
5
1 is Very Difficult, 5 is Very Easy
Was a follow-up required?
*
Yes
No
Reason for No Response or Decline (if applicable)
Please Select
No Answer
Busy
Refused/Not Interested
Language Barrier
Other
Additional Notes
Submit Call Log
Should be Empty: