Service Receipt Log

Appendix J.

Service Receipt Log

OMB Control Number:

Expiration Date:

Strengthening Community Colleges Training Grants Program Round 4 (SCC4) Evaluation Coach Log

To be completed by coaches immediately after each session with a study participant. This log will be completed in Salesforce or a similar college system and will be automatically tied to the specific student that the coach completed a session with.

Public reporting for this form is estimated to average 0.03 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintain the data needed, and completing and submitting the survey. This collection of information is voluntary. You are not required to respond to this collection of information unless it displays a valid OMB control number. Please send comments regarding the burden estimate or any other aspect of this collection of information to the U.S. Department of Labor, Office of the Chief Information Officer, Attention: Departmental Clearance Officer, 200 Constitution Avenue, N.W., Room N-1301, Washington, DC 20210 or email DOL_PRA_PUBLIC@dol.gov and reference OMB Control Number [1290-0xxx]. Please do not send your completed form to this address.

ALL

FILL [PARTICIPANT] WITH NAME FROM DATA IN SALESFORCE

Intro. Please complete this form to describe information t about your meeting with [PARTICIPANT].

m CONTINUE 1

ALL

A 1. What was the date of this meeting?

 

   MONTH   DAY       YEAR 

(1-12) (1-31) (2025-present) 

ALL

A2. Was the meeting held in person or virtually?

Virtually includes meeting with the learner by phone or by video.

m In person 1

m Virtually 2

ALL

A3. About how long did your meeting last? Your best estimate is fine.

minutes

(STRING 3)

ALL

A4. Did you do any goal planning or assessment of participants needs in this meeting?

m Yes 1

m No 2

ALL

A5. Please indicate which resources or services you provided to [PARTICIPANT] today.

Select all that apply

• Transportation support (Specify amount or value) 1

• Emergency funds (Specify amount or value) 2

• Funding for employment-related costs (Specify amount or value) 3

• Funding for education-related costs (Specify amount or value) 4

• Job readiness skill development 5

• Referral for mental health services 6

• Referral for tutoring 7

• Referral for additional financial support 8

• Other (Specify) 99

ALL

A6. Please indicate any other notes you have about this session

(STRING 500)