VRTS MENU SCREENVOTER REGISTRATION TRACKING SYSTEM 99/99/9999 99:00

COUNTY _ _ _ WORKER _ _ _ _ _ _ _

VRTS MENU

PF1 – DHS MENU PF3-INQ PF4–RECORD APP NUMBER

TO INQUIRE ON A REGISTRATION/APPLICATION/DECLINATIONKEY SSN,

OR

X TO RECORD REGISTRATION / DECLINATION DATA

KEY ‘X’, PRESS ENTER

OR

KEY SSN and APPLICATION NO, PRESS PF4

SSN _ _ _ _ _ _ _ _ _

APP NO _ _ _ _ _ _ _ _

“TRANSACTION SUCCESSFUL” OR “SSN NOT FOUND”

ENTER PF4PF4–RECORD APP NUMBER PF3PF3–INQ

VRTS Data Entry Screen VRTS DATA ENTRY 99/99/9999 99:00

COUNTY: _ _ _ WORKER: _ _ _ _ _ _ _ SSN: _ _ _ _ _ _ _ _ _FST NME:________ MI:_ LST NME:___________________

DID APPL/RECIP STATE THAT THEY ARE REGISTERED TO VOTE AT THEIR CURRENT ADDRESS? (Y/N) _

IF NOT REGISTERED TO VOTE WHERE YOU LIVE NOW, WOULD YOU LIKE TO APPLY TO REGISTER HERE TODAY(OR WOULD YOU LIKE US TO MAIL YOU AN APPLICATION TO DO SO[(IF RESPONDING TO A PHONE CONTACT RELATED TO ADDRESS CHANGE?]) (Y/N) _

WAS AN APPLICATION TO REGISTER TO VOTE GIVEN TO THE APPLICANT/RECIPIENT?(Y/N) _

(IF TELEPHONE CONTACT)”WAS APPLICATION TO REGISTER TO VOTE MAILED TO THE APPLICANT/RECIPIENT?” (Y/N) _

WAS A COMPLETED APPLICATION FORM RECEIVED BY DHS? (Y/N) _ APPLICATION NUMBER: _ _ _ _ _ _ _ _

WAS A DECLINATION FORM GIVEN TO THE APPLICANT/RECIPIENT? (Y/N) _

HAS THE APPLICANT/RECIPIENT SIGNED A DECLINATION FACT SHEET? (Y/N) _

HAS THE APPLICANT/RECIPIENT REFUSED TO SIGN EITHER AN APPLICATION TO REGISTER TO VOTE OR TO SIGN A DECLINATION FORM? (Y/N) _

PF5-VRDS MENU, PF2-ADD, PF3-INQ, PF12-CLR SCRN

VRTS Inquiry Screen VRTS INQUIRY 99/99/9999 99:00

COUNTY: _ _ WORKER: _ _ _ _ _ _ _ SSN: _ _ _ _ _ _ _ _ _ FIRST NAME: _____________ MI: _ LAST: ____________________

PF5 - PREV LVL, PF7 - PAGE UP, PF8- PAGE DOWN

DATE OF CONTACT

ALRDYRGSTRD

AGRDRGSTR OFFC

APPLGIV OFFC

MAILAPPL

RECVDCMPLTAPPL

APPLNUM

DECLGIVN

DECLSIGND

DECLREF

WORKER CO

02/04/03 _X_ _X_ _X_ _X_ _X_ P1234567 _X_ _X_ _X_ DECZZZZ _99_

RUN DATE 99/99/9999 TENNESSEE DEPARTMENT OF HUMAN SERVICES PAGE 999VRTS REGISTRATION / DECLINATION TOTALS MONTHLY REPORT BY COUNTY AND STATE   CO ALREADY REG APPLY TODAY APPLIC GIVEN APPLIC MAILED COMPLETE APPL DECL GIVEN SIGNED DECL REFUSED DECL (Y) (Y) (Y) (Y) (Y) (Y) (Y) (Y)  (N) (N) (N) (N) (N) (N) (N) (N) 99 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999   99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999  99 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999   99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999

99 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999

99 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999

99 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999

99 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999  STATE 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999 TOT 99,999 99,999 99,999 99,999 99,999 99,999 99,999 99,999

INFOPAC REPORTMonthly County and State totals of the questions on the VRTS Data

Entry Screen