Form #4 Form #4 Implementation Tracking Form

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Attachment F: Implementation Tracking Form

Demonstration of Health Literacy Universal Precautions Toolkit

Practice Name:

Please use this form to record the expected and actual timing of your implementation activities. Please update and fax/e-mail this form to the project team prior to the webinar, routine check-in calls, and the final site visit.

Tool 1: Form a Team	Expected Date	Actual Date
When did the first meeting of the Health Literacy Team occur?
How often does the team meet?

Tool 2: Assess Your Practice	Expected Date	Actual Date
When did practice members complete the Health Literacy Assessment Questions? (You may provide a range of dates, if appropriate.)
When did the Health Literacy Team meet to discuss the results of your assessment? (You may provide a range of dates, if appropriate.)
When did the Health Literacy Team decide which tools to address?
In addition to Tools 1 and 2, which tools does your practice plan to implement:   Tool 3: Raise Awareness   Tool 4: Tips for Communicating Clearly   Tool 5: The Teach-Back Method   Tool 8: Brown Bag Medication Review   Tool 11: Design Easy-to-Read Material   Tool 12: Use Health Education Material Effectively   Tool 13: Welcome Patients: Helpful Attitude, Signs, and More   Tool 14: Encourage Questions   Tool 16: Improve Medication Adherence and Accuracy   Tool 20: Use Health and Literacy Resources in the Community   Another tool (please specify: _____________________________________________________)

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to participate in this survey.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Form Approved: OMB Number 0935-XXXX Exp. Date xx/xx/20xx. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

Please complete the following items for each additional tool your practice is implementing.

Tool Number:	Expected Date	Actual Date
By what date did your team begin planning the implementation of this tool?
By what date did your team complete an action plan for how this tool would be implemented?
When was the first training conducted related to this tool?
When did you first begin implementing your action plan for this tool?

Tool Number:	Expected Date	Actual Date
By what date did your team begin planning the implementation of this tool?
By what date did your team complete an action plan for how this tool would be implemented?
When was the first training conducted related to this tool?
When did you first begin implementing your action plan for this tool?