Design Implementation Data

Appendix B2 CHW Data Collection Form-Design Implementation Data.docx

Frontier Community Healthcare Network Coordination Grant

Design Implementation Data

OMB: 0915-0383

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Please select the reporting period

Beginning – 12/31/2013


1/1/2014 – 3/31/2014


4/1/2014-6/30/2014


7/1/2014-8/31/2014



Table 1: Recruitment information

Recruitment Information

Location

Client Recruitment attempts

Source of attempts

Method(s) of recruitment

Number of new enrollments

Understood reason(s) for unsuccessful attempts
































Please select the reporting period

Beginning – 12/31/2013


1/1/2014 – 3/31/2014


4/1/2014-6/30/2014


7/1/2014-8/31/2014



Table 2: Resources Required

Resources Required

Location

Total hours spent by CHWs on programs?

Were any additional resources used?

Financial

(free text)

Equipment

(free text)

Volunteer work

(free text)

Other (explain)





































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AuthorSharanjit Toor
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