5 Checklist

O.M.B. 0925-0491

Exp. XX/XX

Evaluation Instruments: Set 2

Evaluation Instrument: "With Every Heartbeat is Life" Checklist

The "With Every Heartbeat Is Life" Activity Commitment checklist was implemented in January 2009/2010. CHAN members from the five groups submitted forms indicating the 4 health educational activities they would complete during the following year. Suggestions were based on the activities taught during the "With Every Heartbeat Is Life" training. CHAs were to submit their summaries and pictures of activities at the end of each year. We have received checklists from all groups but not the summaries.

Public reporting burden for this collection of information is estimated to average 6-15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0491). Do not return the completed form to this address.

Evaluation Instrument: Set 5

“With Every Heartbeat Is Life”

JHS CHAN Activity Commitment Checklist

Please indicate the four activities* you will conduct during the next year:

Complete the “My Family Health History” and discuss Heart Disease Risk Factors at the next _____family gathering (Easter, Mother’s Day, Independence Day, Thanksgiving, Christmas, etc…)

_____ Complete the heart disease risk factor activity at my church’s annual health fair

_____ Organize a walking club in my community, work setting or church

_____ Demonstrate the stretching activities in Session 3 at upcoming JHS Community Walks

Conduct monthly exercises at a nursing home, assisted living program, apartment for the elderly _____or senior citizen center

Conduct heart healthy living sessions with elementary and middle school aged children in after _____school settings, municipal recreational facilities, boys and girls clubs, and/or YMCAs

• Heart healthy snacks (Session 6)

• Heart healthy sleep

• Heart healthy physical activity (Session 3)

• Smoking Harms (Session 10)

• Think Before You Drink: Hidden Sugars in Common Beverages (Session 7)

• Understanding serving sizes and reading food labels (Sessions 5 & 6)

Designate a Heart Health Day at church and discuss Heart Disease Risk Factor Activity. Supply fact _____sheets with area hospital heart examination days and contact information

Conduct a blood pressure screening in my CHAN community, Disseminate literature with _____information from Sessions 4 & 5

Arrange community wide heart healthy cooking demonstrations for adults utilizing information _____found in Sessions 4, 5, 6, 7, 8 & 9

Arrange community wide heart healthy cooking demonstrations for children and

_____youths (Session 8)

_____Conduct 11 week With Every Heartbeat Is Life training

_____Display heart health literature and resources at health fairs in my community

Conduct presentations sharing personal “heart healthy” life experiences (surviving heart attacks, _____living with CHF, or other relevant experiences

______Jan-March 2009 _______ April –June _______ July-Sept _______ Oct-Dec.

Signature ______________________________________ Date__________________________

*Activities may be conducted at churches, civic organizations, sororities, fraternities, lodges, etc.