Date	Base or Focus Program	Date	Base or Focus Program
Client Name:	Client Name
Check (one of each in 1-4)	Check (one of each in 1-4)
1. Office Farm Visit Phone Email One to One	1. Office Farm Visit Phone Email One to One
2. White Black Asian AmIn/AlNat H/PI 2 or more	2. White Black Asian AmIn/AlNat H/PI 2 or more
3. Hispanic/Latino Non-Hispanic/Latino	3. Hispanic/Latino Non-Hispanic/Latino
4. Male Female	4. Male Female
Time with contact:	Time with contact:
Travel expenses (Mileage & Food):	Travel expenses (Mileage & Food):
Travel time to and fro:	Travel time to and fro:
Observed/Client’s report of Impact of practice change/adoption & Other comments on back of card	Observed/Client’s report of Impact of practice change/adoption & Other comments on back of card
Date	Base or Focus Program	Date	Base or Focus Program
Client Name:	Client Name
Check (one of each in 1-4)	Check (one of each in 1-4)
1. Office Farm Visit Phone Email One to One	1. Office Farm Visit Phone Email One to One
2. White Black Asian AmIn/AlNat H/PI 2 or more	2. White Black Asian AmIn/AlNat H/PI 2 or more
3. Hispanic/Latino Non-Hispanic/Latino	3. Hispanic/Latino Non-Hispanic/Latino
4. Male Female	4. Male Female
Time with contact:	Time with contact:
Travel expenses (Mileage & Food):	Travel expenses (Mileage & Food):
Travel time to and fro:	Travel time to and fro:
Observed/Client’s report of Impact of practice change/adoption & Other comments on back of card	Observed/Client’s report of Impact of practice change/adoption & Other comments on back of card