Diaper Distribution Data Collection

Please complete this form with families every time they receive diapers.

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* 1. Date of Service

Today's Date

Date

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* 2. Organization Name

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* 3. In which county (or reservation) does the family reside?

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* 4. How many children are receiving diapers?

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* 5. How many total diapers/pull-ups/briefs are you distributing to this family? (Please write one TOTAL for all types combined - i.e. do not case or sleeve count, or size or type)

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* 6. If distributing baby wipes, how many total packs did this family receive?

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* 7. This client/family:

is receiving diapers for the first time ever from the DDDRP program

has received diapers at least once already from the DDDRP program