RBTV Contact Summary Form

Contact Summary Form

To be completed by the RBTV Advisor after each engagement with an applicant. Note: Additional sections are to be completed if an essay or report card have been collected during the meeting.
Applicant Full Name

First NameLast Name
RBTV Advisor

First NameLast Name
If first meeting, indicate the best method to contact the Applicant and the Applicant's Parent/Guardian.
Date/Time of this meeting:

MonthDayYearHourMinutesAM/PM Option
Method

Other
Highlights of topics covered by RBTV Advisor:
Highlights of topics dicussed by Applicant:
What was the level of the Applicant's participation?

How do you think the meeting went?

	1	2	3	4	5

1 is Difficult, 5 is Very Well

Scores of "1" require comment:
What is your impression of the Applicant to date?
Other Comments (If applicable)
Follow-up items or topics for the next meeting:
Report Card (if collected)
Math
English/Lit
Science
Physical Education
Humanities/Social Science
Other
Other
Other
If the information is available to you, what is the general impression that teachers have of him?
Essay (If collected)
Topic
Reflect understanding of the topic:
Submitted on time? If not, provide explanation:

Level of Effort

	1	2	3	4	5

1 is Min, 5 is Max

Contact Summary Form