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 Name Last Name
RBTV Advisor

First Name Last Name
If first meeting, indicate the best method to contact the Applicant and the Applicant's Parent/Guardian.

Home Phone Mobile Phone E-mail Facebook
Date/Time of this meeting:

Month Day Year
at
Hour Minutes AM/PM Option Date Picker Icon
Method

In-person Phone Video Chat
Highlights of topics covered by RBTV Advisor:
Highlights of topics dicussed by Applicant:
What was the level of the Applicant's participation?

Actively participated in the conversation by answering questions fully and asking questions Answered all questions but asked few or no questions Asked questions but did not provide full answers to questions asked Did not actively participate

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:

Yes No
Submitted on time? If not, provide explanation:

Level of Effort

	1	2	3	4	5

1 is Min, 5 is Max

Your assessment
Date/Time of next meeting:

Month Day Year
at
Hour Minutes AM/PM Option Date Picker Icon
Should be Empty:

Contact Summary Form