Providers

Client Data Collection and Reporting

Monthly Participant/Staff Summary (a.k.a. 711 form)

Some service programs may be required to complete a 711 form rather than a 600/610 form. The specific form used is based on what SPC code is identified for the specific service provided. The State has determined which SPCs require a 711 form and which require a 600/610 form. The County Contract Manager will communicate which reporting process is required for each program through its annual contracts. Note that the Contract Manager may require a 600/610 form despite the program being one that has a 711 form-appropriate SPC code.

The 711 Form may be used only for these types of services.
SPC Code Description Reporting Units
107 Specialized Transportation & Escort Trips One-Way Trip
403 Recreation & Alternative Activities Staff Hours
408 Community Prevention Staff Hours
501 Crisis Intervention Staff Hours
601 Outreach Staff Hours
602 Information & Referral Contacts
603 Intake Assessment Contacts
605 Advocacy & Defense Resources Staff Hours
606 Health Screening & Accessibility Staff Hours
701 Training & Development Staff Hours
702 Agency / Systems Management Staff Hours
Monthly Participant/Staff Summary Form (711 Form)
Monthly Participant/Staff Summary Form Instructions

If you have questions about this report, please call your designated data entry contact.

04/30/2014