Breastfeeding Peer Counselor Weekly Activity Report
Exhibit 6-N
Peer Counselor Name:___________________________
Week Ending: ___________ Peer Counselor signature:_________________________________________
Daily Total Hours
Other: ______________
Home Study
Clerical / Admin
Consult w Peer Mgr/Sup.
PC Promotion
Peer Meeting
Postpartum
Prenatal
# Stamps Used
Mailed information
Other contact
Class
Hospital Visit / Miles
In clinic / individual
Home Visit / Miles
Telephone contact
Date
Training / In-service
Type & Time of Contact
Other Peer Activities
Client Contacts
Totals
Page ____ of ______
Total Hours ______
Remarks
Time:
Miles:
Round time to the nearest 5 minutes.
MN WIC 06
4/06