Non-Contact Positive Interaction Log Form
Log brief positive interactions that occur without physical contact using this form.
Date and time of interaction
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location or context of the interaction
*
Your full name
*
First Name
Last Name
Names or roles of other participant(s)
*
Method of interaction
*
Please Select
Verbal (in person, at a distance)
Phone call
Video call
Text message or chat
Email
Social media
Other
Brief description of the positive interaction
*
What was the main topic or focus?
*
Please Select
Encouragement
Recognition
Gratitude
Support
Celebration
Other
How did the interaction make you feel?
*
Very positive
Positive
Neutral
Somewhat positive
Do you think a follow-up is needed?
*
Yes
No
Not sure
Additional notes or comments
Submit Log
Should be Empty: