Sample Tracking Form

Attachment D: Sample CASPER Tracking Form
County: …………Cluster # (i.e., 1-30): ……. # of Houses in the Cluster………Interviewer: ………Date of Interview: ….. / ….. /….
Instructions: Use one tracking form per cluster. Check where appropriate, but try to choose only one best option for each of the five categories. Go as far down
the list as possible for each site you visit. Use neighbors to find information if no resident is available.
Sampled Housing Units

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1) ACCESS
House is Accessible
House is Inaccessible
2) TYPE OF DWELLING
No housing structure
Mobile Home
Single Family Home
Apartment or Condo
Other
3) DAMAGE
None or Minimal
Damaged
Destroyed
4) ANSWER
Door was answered
Appears as though someone is
home but no answer
Appears vacant
Nobody home
after…

st

1 visit
nd

2 visit
rd

3 visit
5) INTERVIEW
Language Barrier
Refused to Participate
Interview begun, not finished
Interview Completed
Survey # (i.e., 1–7) from
Completed Questionnaire:

Community Assessment for Public Health Emergency Response Example Tracking Form (reverse side)
Instructions: Use this page to keep notes on which houses may need return visits.
Sampled Housing Unit:
1.
2.
3.
4.
5.
6.
7.
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9.
10.
11.
12.
13.
14.
15.
16.
17.