Att 5a_ATSDR Health Education Activity Tracking (HEAT) Form

Form Approved

OMB Control Number: 0923­xxxx
Expiration Date: xx/xx/201x
ATSDR estimates the average public reporting burden for this collection of information as 3 minutes per response, including the time for
reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 CDC/ATSDR Information Collection
Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-xxxx).

ATSDR Health Education Activity Tracking
Title
State

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Cost Recovery #
Site or Activity Name
Site Related Education?
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Was activity completed by cooperative
agreement partner? (If yes, check box)
Is activity related to the Choose Safe Places for
Early Childcare and Education program? (If yes,
check box)
Date Started
Date Completed
Educator Type

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Educator
Evaluation Method

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HE/CI Delivery Method

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# Community Participants
# Understanding Health Risk
# Understanding Pathways
# Knowing Contact for Concerns
Brief Description of Activity

Were Materials Distributed?
# Receiving Materials
# Understanding Materials

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