Maryland Kinship Care Resource Center

DHR/SSA-12-001-S Attachment P

Maryland Kinship Care Resource Center Monthly Progress Report

Reporting Month: ______Year______Contractor: (Official Company Name) ______Contact Person: ______Telephone Number: ______

I. Total number of requests during month______

II. Provide number for each type of communication:

A. Telephone______B. E-mail______C. Walk-In______D. Referral______E. Other (please list)______

III. Categories of Requested Services: Provide the number of requested.

A. Financial/Medical ______B. Supplemental Food Assistance (Food Stamps)______C. Educational ______D. Childcare______E. Custody______F. Counseling______G. Housing______H. Advocacy______I. Other (explain)______

IV. Demographic Information:

A. Kin’s relationship: Grandparent_____ B. Aunt/Uncle______C. Cousin______D. Adult Sibling______E. Other (Explain)______F. Age of Caregiver: Under age 60_____ or Over age 60____ G. Formal Kinship______or Informal Kinship______(LDSS Involved) (No LDSS Involved) H. List Maryland jurisdiction represented by relative caregivers:  Alleghany County____  Anne Arundel County______ Baltimore City______ Baltimore County____  Caroline County _____  Carroll County _____  Cecil County ______ Charles County _____  Dorchester County___  Frederick County ____  Garrett County ______ Harford County _____  Howard County _____  Kent County ______ Montgomery County ___  Prince George’s County____  Queen Anne’s County_____  St, Mary’s County______ Somerset County ______ Talbot County ______ Washington County ______ Wicomico County ______

V. Provide any accomplishment(s) during the month which promotes one of the three project objectives. (Refer to the Request for Proposal). ______.

VI. Share any barriers or challenges during the month and how resolved. ______

VII. General comments. ______