ATSDR Health Education Activity Tracking (HEAT) Form

Form Approved

OMB Control Number: 0923‐0057 Expiration Date: 07/31/2020

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 ﴾0923‐0057﴿.

ATSDR Health Education Activity Tracking

HEAT Site Information

Title * State

Please select a value...

Cost Recovery # Site or Activity Name *

HEAT Activities Information

Site Related Education? Was activity completed by

Is activity related to the

Is activity related to COVID‐

Site Related Education?

cooperative agreement partner? ﴾If yes, check box﴿

Cooperative Agreement

Choose Safe Places for Early Childcare and Education program? ﴾If yes, check box﴿

19? ﴾If yes, check box﴿

Partner Choose Safe Places program

Date Started * Date Completed *

Educator Type * Coop Partner

Educator Name

Evaluation Method * None of the above

HE/CI Delivery Method * None of the above

# of Community Participants * # Understanding Health Risk

# Understanding Pathways # Knowing Contact for Concerns

Brief Description of Activity *

Were Materials Distributed? # Receiving Materials # Understanding Materials Were Materials

Distributed?

Link

Type the Web address:

Text to display:

Attachments

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