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1 <br />2 <br />3 <br />4 <br />5 <br />6 <br />7 <br />8 <br />9 <br />10 <br />11 <br />12 <br />13 <br />14 <br />15 <br />16 <br />17 <br />18 <br />19 <br />20 <br />21 <br />22 <br />23 <br />24 <br />25 <br />26 <br />27 <br />28 <br />1.1.3. Ethnicity; <br />1.1.4. Date of birth; <br />1.1.5. Sex; <br />1.1.6. Referral reason(s); <br />1.1.7. Services recommended; <br />1.1.8. Services provided; <br />1,1.9. Date services delivery begins; <br />1.1.10. Status indicators (e.g. previous abuse reports, existing <br />health problems, etc.); <br />Primary language spoken;• <br />1.1.12. PSSF outcome measures as identified in Paragraphs 3 <br />through 9 Date service delivery ends: <br />1.1.13. of this Exhibit; and <br />1.1.14. PSSF service categories as identified in Paragraphs 3 <br />through 9 of this Exhibit. <br />11.2 Reports shall be prepared in a format approved in writing by <br />ADMINISTRATOR and shall be transmitted to the FaCT Program Coordinator and <br />Social Services Agency (SSA) Contract ADMINISTRATOR by the twentieth (20") day <br />of each month for the preceding month of services. <br />11.3 CONTRACTOR shall complete registration forms and attendance sheets <br />for every service delivered to participant(s) unless specifically exempted by <br />ADMINISTRATOR. <br />11.4 CONTRACTOR shall complete the Fa CT standardized Marketing Outreach <br />Log and shall submit to ADMINISTRATOR quarterly, ten (10) calendar days <br />following the end of each quarter. <br />11.5 ADMINISTRATOR and CONTRACTOR may mutually agree in writing to add, <br />delete, waive, or otherwise modify reporting requirements as stated -in this <br />paragraph. <br />(FNH0209)' <br />28 of 42 <br />(3/18/09) <br />