Form 1 Tracking Form

Healthy Native Babies Project

Materials Distribution Tracking Form

The purpose of this form is to provide a framework for reporting on your Healthy Native Babies Project distribution activities funded by the resource stipend. Please call 1-888-996-9916 if you have any questions.

Tribe/Organization Name:      

Contact Name:      

City:      

State and Zip Code:      

Phone Number: (Including Area Code)      

Email:      

IHS Area:      

Resource Stipend Report Components

Please respond to each of the following sections.

I. Materials Distributed – Please describe type and number of Healthy Native Babies Project materials that were made available for distribution, at locations or during events, and describe the number actually distributed to the target population, if known.

Healthy Native Babies Project (HNB) Material Type	Setting or Event	# Provided to Setting/ Event	# Distributed to target audience (if known)*
Example: Poster	Various community locations	20	20
Example: Brochure	Tribal Home Visiting Project	50	25

*The number distributed to target audience is the actual number of materials handed out. This number would be less than the number provided to the setting/event if there were leftover copies. Provide an estimate if exact number is not known.

II. Activities – Describe the community outreach activities conducted with your Healthy Native Babies Project resource stipend including the specific types of activities used to reach parents, caregivers, or hard to reach groups. Use the table to report the number of individuals reached through the outreach activities.

• Brief narrative:      

Outreach Activity (e.g., home visit, community event)	Number of Individuals Reached
	Parents/ Caregivers	Elders	Community at large	Service Providers	Other:

III. Results of Activities – If you conducted assessments of your organization’s outreach activities that used Healthy Native Babies Project materials, please describe your results. For example, please share the results of satisfaction assessments, feedback from parents or service providers on the Healthy Native Babies Project messages or materials, or pre and post-test results.

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IV. Distribution Successes and Challenges – Describe the successes and challenges you experienced in distributing Healthy Native Babies Project materials. Your responses will be used in the development of future Healthy Native Babies Project activities and resources.

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