Form 1 KAPPA Activity Tracker

OMB # 0925-0701

Expiration Date: 02/2021

Kappa Safe Infant Sleep Community Engagement Project
Activity Tracking Form

Public reporting burden for this collection of information is estimated to average 30 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 (0925-0701). Do not return the completed form to this address.

1. What geographic area did the project activity serve? (Include county and ZIP code for each area. If you know the region number for your county and/or ZIP code, please include it.)

Enter text here.

2. Please describe all of the SIDS/safe infant sleep outreach activities that you conducted during this grant cycle (June 17, 2018, through August 31, 2018). Be as specific as possible. Please use additional pages if needed.

• Total Number of Events: Enter text here.

• Total Number of Participants Who Attended Events: Enter text here.

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Activity	Description	Event Date	Number of Attendees	Activity Audience	Encounter Type: Awareness vs. Educational
Example: Community of Committed Men – Protecting Our Future	Columbus Alumni Chapter representatives partnered with staff from the Friendly Center in Columbus to train men on safe infant sleep using the Safe to Sleep® educational video and print materials. Baby 1st Network provided a supplementary in-kind donation for this education initiative, which covered meal expenses for training participants.	7/24/2018	25	Expectant dads New dads Grandfathers	Educational
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3. Did training or event participants have trouble understanding any of the safe infant sleep messages? If so, which message(s)?

Enter text here.

4. What parts of this project worked well, and which would you do again to make your outreach successful? Please explain.

Enter text here.

5. Do you feel you have the necessary information and resources to continue raising awareness about ways to reduce the risk of SIDS and promoting safe infant sleep in your community?

☐ Yes

☐ No

6. If no, what types of information or resources would be most helpful to you?

Enter text here.

7. With 1 being not at all helpful and 5 being very helpful, select a box below to describe how helpful the following materials were in your outreach activities.

1. Promotional materials (such as event flyer template, sample social media posts, badges)

   1 Not at all helpful	2	3	4	5 Very helpful
   ☐	☐	☐	☐	☐

2. Presentations (such as 15-minute and 30-minute slide sets)

1 Not at all helpful	2	3	4	5 Very helpful
☐	☐	☐	☐	☐

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3. Activity planning materials (such as tips and tricks handout, planning checklist)

   1 Not at all helpful	2	3	4	5 Very helpful
   ☐	☐	☐	☐	☐

4. Educational materials (such as educational flipbook and safe sleep brochures)

1 Not at all helpful	2	3	4	5 Very helpful
☐	☐	☐	☐	☐

8. Please provide your contact information below.

Name of Chapter:	Enter text here.
Type of Chapter: (Graduate, Undergraduate, Silhouette)	Enter text here.
Date of Report: (Month/Day/Year)	Enter text here.
Contact Person:	Enter text here.
Telephone:	Enter text here.
Email:	Enter text here.
Address:	Enter text here.

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