National Office Outreach Reporting

National Amyotrophic Lateral Sclerosis (ALS) Registry

Attach_13B-National Office Outreach Reporting Form final.xlsx

National Office Outreach Reporting

OMB: 0923-0041

Document [xlsx]
Download: xlsx | pdf







Thank you for completing this important information about



the way you are conducting outreach for the National ALS



Registry. Please submit a form monthly for your organization.












Org Code



















Clinic, Support Group, Seminar, Other group activities





Kaye, Wendy (ATSDR/DTHHS/EHSB) (CTR): Indicate if a clinic, support group, seminar, or other group activities Activity Date # Registry information kits distributed # people talked to about the Registry # people helped sign-up for the Registry City and State




























Total




















Social Media and local mailings (e.g., tweet, email blast, newsletter)





Activity Date # City and State





























Total




















Fundraising event (e.g., walk, golf tournament)





Type of event Date # attendees Materials distributed or displayed City and State




























Total




















Outreach calls made where the Registry was discussed





# calls City and State































Total













File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

© 2024 OMB.report | Privacy Policy