New World Survival · Program design workbook
Wellness Check Program Workbook
Build a voluntary contact program with a narrow promise, trained callers, written escalation rules and minimal records.
Complete this workbook with local emergency management, safeguarding, privacy and legal reviewers. It is not a participant roster.
Program authority
1. Define who owns the service
Institution or network
Version date
Program lead
Backup lead
Governing body approval
Next review date
Local reviewers and escalation partners
| Role | Name or agency | What they approve | Activation contact |
|---|---|---|---|
| Emergency management | |||
| Public safety | |||
| Safeguarding | |||
| Privacy or legal | |||
| Health or human services |
Service boundary
2. Write the promise before collecting information
One-sentence service promise
Activation conditions and operating hours
Services this program does not provide
- Continuous monitoring or guaranteed rescue
- Emergency dispatch
- Medical assessment or medical advice
- Personal care, transportation or home entry
- Storage of clinical records
- Financial transactions or benefit eligibility decisions
Additional local boundaries
Promise only what can be staffed and supervised.
If the institution cannot maintain the stated contact interval, it must have a participant notification and closure procedure.
Voluntary enrollment
3. Collect only what the service needs
| Information item | Why it is necessary | Who may access it | When it is deleted |
|---|---|---|---|
| Participant name or preferred identifier | |||
| Preferred contact method | |||
| Preferred language or communication format | |||
| Contact schedule | |||
| Participant-approved backup contact | |||
| Participant-approved escalation preference | |||
| Consent date and the date we will ask again |
Enrollment explanation
- Participation is voluntary.
- The service and its limits are stated in plain language.
- The participant chooses contact methods and approved contacts.
- The participant is told who can see the record.
- The participant can update or withdraw.
- No diagnosis, immigration status, financial record or unrelated household detail is requested.
Never place real participant information in this shared workbook.
Keep the operational roster in the locally approved system with access, retention and deletion controls.
Caller assignment
4. Control who makes contact
| Caller role | Training completed | Supervisor | Authorized information | Backup |
|---|---|---|---|---|
Caller identity and safety rules
- Use an approved number or account.
- Confirm identity without requesting sensitive secrets.
- Do not leave detailed messages unless the participant approved them.
- Do not use personal notes, personal cloud storage or social media messages.
- Do not promise an outcome outside the program.
- Report a safeguarding or boundary concern to the supervisor.
Contact script
5. Use a short, consistent conversation
| Step | Approved wording or prompt | Caller action |
|---|---|---|
| Identify | State your name, institution and the voluntary program. | Confirm this is a safe time to talk. |
| Explain | State what this contact can and cannot do. | Offer another communication method if needed. |
| Ask | Use the locally approved short questions. | Avoid diagnosis, interrogation or pressure. |
| Respond | Use only approved referral and escalation options. | Read back the agreed next step. |
| Close | Confirm the next contact or program closure. | Record only the outcome code and necessary action. |
Locally approved script
Communication accommodations and translation process
Escalation card
6. Decide what the caller does next
| Situation | Caller action | Notify | Record |
|---|---|---|---|
| Immediate threat to life or safety | Call 911 first, then tell the supervisor. Follow the call-taker's instructions. | ||
| Urgent welfare concern without confirmed immediate danger | Tell the supervisor now. The supervisor contacts the partner named on the card. | ||
| Missed contact | Follow the written attempt schedule, then the participant-approved escalation path. | ||
| Routine request within the referral list | Provide the verified referral and confirm whether follow-up is requested. | ||
| Request outside the service | State the boundary and use the approved referral or supervisor path. | ||
| Caller feels unsafe or uncertain | Pause, contact the supervisor and document the minimum necessary outcome. |
Missed-contact maximum
Maximum attempts: ________ over ________ hours, then the supervisor takes the next step.
Call 911 if you hear this
During heat: confusion, dizziness or no response from someone who answered. During cold: confusion, slurred speech, drowsiness or fumbling. CDC calls hypothermia a medical emergency; our card treats these signs on a call as a 911 call. Our card's rule at any time: trouble breathing, a fall with injury, or a person who says they cannot get up or get out. A caller is not expected to tell these apart. If you are worried enough to wonder, call.
Referral numbers
| Need | Number | What it is |
|---|---|---|
| Local help and shelters | 211 | Information on disaster evacuations, shelters, and food and clothing distribution. |
| Disaster distress | 1-800-985-5990 | SAMHSA's Disaster Distress Helpline, call or text, 24 hours a day. |
| Suicide and crisis | 988 | The 988 Lifeline, by call, text or chat, 24 hours a day. |
| Services for older adults | 1-800-677-1116 | The Eldercare Locator connects older adults and families to local services. |
| Local numbers | ||
| Local numbers |
Emergency numbers, safeguarding contacts and after-hours process
Local responders must review this card.
The institution should not invent welfare-check or emergency-dispatch procedures without the agencies expected to receive those requests.
Activity record
7. Record outcomes, not stories
| Approved code | Meaning | Required next action | Retention period |
|---|---|---|---|
| C | Contacted, no request | ||
| R | Contacted, request passed to coordinator | ||
| N1, N2, N3 | No answer, attempt number | ||
| B | Backup contact reached | ||
| S | Escalated to supervisor | ||
| E | 911 called | ||
| W | Withdrew from the service |
Minimum activity log fields
- Participant identifier
- Date, time and authorized caller
- Outcome code
- Required next action and owner
- Completion time for an escalation
Information controls
8. Protect, review and delete records
Approved storage location
Record custodian
Access approval
Access review frequency
Roster retention rule
Activity log retention rule
Deletion method
Incident reporting contact
- Access is limited to assigned roles.
- Shared accounts are not used.
- Exports and printed copies are controlled.
- Withdrawn and expired records are deleted on schedule.
- Access is removed when an assignment ends.
- A lost device, misdirected message or improper access is reported immediately.
Practice and correction
9. Exercise the full contact path
| Test | Expected result | Finding | Owner and due date | Retest |
|---|---|---|---|---|
| Participant enrollment and withdrawal | ||||
| Accessible contact method | ||||
| Missed contact procedure | ||||
| Urgent welfare escalation | ||||
| Emergency procedure | ||||
| Supervisor handoff | ||||
| Record access and deletion | ||||
| Program closure notice |
Lessons and corrections
Activation decision
10. Approve the program or hold it closed
- The service promise and non-scope are approved.
- Enrollment is voluntary and uses the minimum necessary information.
- Caller identity, scripts and supervision are ready.
- Local agencies reviewed the escalation card.
- The escalation card sets the maximum attempts and hours for a missed contact.
- Accessible contact methods are available.
- Record access, retention and deletion controls are active.
- The exercise findings were corrected and retested.
- Closure and participant-notification procedures are ready.
Unresolved condition and temporary control
Program lead approval
Date
Privacy or legal review
Safeguarding review
Emergency partner review
Next exercise
Hold the program closed if the escalation path or record controls are incomplete.
A small, honest service is safer than a broad promise the institution cannot carry out.