Att 5e_ATSDR Success Story Form

Form Approved
OMB Control Number: 0923-xxxx
Expiration Date: xx/xx/201x
ATSDR estimates the average public reporting burden for this collection of information as 1 hour 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 Success Story Form
Project or Site Name
Attachments

File Attachment

APPLETREE
Is the success story from an APPLETREE
partner?

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Choose Safe Places
Is this a success story for the Choose Safe
Places for Early Care and Education (CSPECE)
program?

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City
State

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POC
List who should be contacted for further
information about the success story.
Brief Summary
In 1­3 sentences, give a brief summary of the
success story.
Background
In 140­250 words, describe relevant
background of site or project. Include dates
and who was involved.
Intervention/Action taken
In 140­250 words, describe the solution,
intervention, or action that was taken.
Accomplishment/Impact
In 140­250 words, describe the impacts,
outcomes, and results of the actions that were
taken.
Link
Add a relevant link to the site or project, if
applicable.

Click here to insert a hyperlink