Appendix D - Staff Activity Logs

APPENDIX D
RETAIN STAFF ACTIVITY LOGS

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INSTRUCTIONS FOR COMPLETING THE RETAIN
STAFF ACTIVITY LOG
Mathematica, the national evaluator of RETAIN, is asking you to record how you spend your
time over the course of a week on 13 RETAIN activities using the attached log. These activities
represent the components of what RETAIN program staff might do on a day-to-day basis. In
completing the attached log, please note the following:
•

Your participation is voluntary and should take no more than five minutes per day.

•

Table 1 provides descriptions of the activities we are interested in tracking. To help you
record your time, the table includes examples from your RETAIN program corresponding to
these activities.

•

At the end of each day from DATE to DATE, please use the log to record how much time
(in half-hour [30 minute] increments) you spent on each activity. You are not expected to
have spent time on all of the activities listed.

•

Record time for an activity only if the work was a substantive effort related to that activity.
For example, time spent helping a participant developing an individual return to work plan
would be recorded as “return to work services” activity, whereas time spent referring a
participant to an employment service provider would not (and would instead be recorded as
a “case management services” activity).

•

The 11th activity in the log is where you should record RETAIN-related travel time. The
12th activity is an ‘Other’ category in which you may record time spent on RETAIN-related
work that does not correspond to any of the first 10 activities.

•

Do not record time spent on activities unrelated to RETAIN.

•

The total hours recorded should sum to the number of hours that you worked that day on
RETAIN, including any “after hours” work.

•

We will use the information from the completed logs, along with other information that we
will collect as part of the national evaluation of RETAIN, to develop an understanding what
is happening in your RETAIN program and to estimate the costs of activities on which staff
spend their time. It will also help other organizations to replicate your program.

•

[Additional instructions proposed by each RETAIN program, if any]

•

If you have any questions about how to complete the log, contact us at
XXXXX@mathematica-mpr.com or call XXX-XXX-XXXX.

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Table 1: Evaluation activities and examples from your [RETAIN PROGRAM]
Activity

Program-specific examples of services and
activities

1. Recruitment and enrollment—activities related to
recruiting, screening, and enrolling RETAIN participants

[Cell to contain information provided by
each RETAIN program]

2. Case management services—services that involve working
with RETAIN participants on issues not included in categories
below, such as checking in or connecting participants to other
services.

[Cell to contain information provided by
each RETAIN program]

3. Return-to work services—activities to support return to
work including development and implementation of a plan to
support the employee in returning to or staying at work,
vocational counseling, and job search assistance

[Cell to contain information provided by
each RETAIN program]

4. Care coordination—activities to coordinate health care for
RETAIN participants. Routine communication with heath care
providers should be recorded under #5.

[Cell to contain information provided by
each RETAIN program]

5. Communication with health care providers—activities
related to communicating with health care providers about a
participant’s activity plan and possible accommodations

[Cell to contain information provided by
each RETAIN program]

6. Communication with employers—activities related to
communicating with employers about return to work and
possible accommodations

[Cell to contain information provided by
each RETAIN program]

7. Training for providers or employers—activities related
training health care providers on occupational health best
practices or employer on best stay at work/return to work
practices.

[Cell to contain information provided by
each RETAIN program]

8. Program administration: evaluation—other activities
related to evaluation, reporting, and monitoring

[Cell to contain information provided by
each RETAIN program]

9. Program administration: training and technical
assistance—activities related to the receipt or delivery of staff
training to improve knowledge and skills in working with
individuals with recently-acquired injuries and disabilities

[Cell to contain information provided by
each RETAIN program]

10. Program administration: other—all other activities related
to oversight of the program and staff, reporting requirements
of the Department of Labor, and general administration

[Cell to contain information provided by
each RETAIN program]

11. Travel—time spent traveling to or from meetings, events, and
trainings, including those not specifically with or on behalf of
enrollees. Do not include time spent commuting to work.

[Cell to contain information provided by
each RETAIN program]

12. Other RETAIN—any activities related to your RETAIN
program that do not fall into the above categories

[Cell to contain information provided by
each RETAIN program]

13. Leave—time or days taken off (from your usual RETAIN
work period) for holidays, vacations, illness, or
personal/family reasons

[Cell to contain information provided by
each RETAIN program]

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Hours
Activity
Total hours worked on RETAIN—Please write a zero in the days you
do not usually work
1.

Recruitment and enrollment

2.

Case management services

3.

Return to work services

4.

Care coordination

5.

Communication with health care providers

6.

Communication with employers

7.

Provider or employer training

8.

Program administration: evaluation

9.

Program administration: training and technical assistance

Monday

Tuesday

Wednesday

Thursday

Friday

10. Program administration: other
11. Travel
12. Other RETAIN—any activities related to your RETAIN program
that do not fall into the above categories; if you use this category,
please provide a brief explanation in the line below
If you use the other RETAIN category, please write in this space to
briefly tell us what you did
13. Leave—time or days taken off (from your usual RETAIN work
period) for holidays, vacations, illness, or personal/family reasons;
you do not need to explain the type of leave taken
Please make sure the hours for each day sum to the total hours that you entered in the first row.
If you have any questions about how to complete the log, contact XXXXX@mathematica-mpr.com or call XXX-XXX-XXXX.
After you’ve completed the log for the week, please e-mail the form to XXXXX@mathematica-mpr.com or fax it to [staff name] at XXX-XXX-XXXX.

Saturday

Sunday