Form 0920-1161 Partnership Activities Form

Form Approved

OMB No: 0920-New

Exp. Date: XX/XX/XXXX

Evaluation of Enhancing HIV Prevention Communication and

Mobilization Efforts through Strategic Partnerships

Attachment 3f

Partnership Activities Form

Public reporting burden of this collection of information is estimated to average 25 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

Partnership Activities Form
Organization: Organization Name Begin date: Click here to enter a date. End date: Click here to enter a date. Partnership type: If an unfunded partner, is your organization affiliated with the Business Response to AIDS (BRTA) initiative? If a funded partner, are you a part of Partnering and Communicating Together to Prevent HIV (PACT)?
Point of contact: Name
Email: Email Address			Phone: Please include area code.
EVENT
Event: Name of Event		Event location: (If applicable) City, State, Zipcode
		Approximate attendance: How many people were there? Event type:
Description: Please provide a description of the event. Please describe the audience and key highlights .
Were HIV tests administered? Number of HIV tests administered: Click here to enter text. Number of preliminary positives: Click here to enter text.
Did other partners (internal or external), chapters or affiliates of your organization, or sponsors have a role or help in this activity? If yes, list all involved:
Materials Distributed
Were any materials distributed?
If yes, please select campaign, materials type and enter quantities below: Campaign: Materials Type: Quantity: Click here to enter text. Campaign: Materials Type: Quantity: Click here to enter text. Campaign: Materials Type: Quantity: Click here to enter text. Campaign: Materials Type: Quantity: Click here to enter text. Campaign: Materials Type: Quantity: Click here to enter text. Campaign: Materials Type: Quantity: Click here to enter text. Campaign: Materials Type: Quantity: Click here to enter text. Other Materials: Please describe any other materials used and the corresponding quantities. Please select distribution channel(s) (check all that apply): ☐ Funded Partner ☐ Unfunded Partner ☐ Participant Network ☐ CDC and CDC-INFO ☐ Bulk Order ☐ Event ☐ Conference ☐ Gay Pride Event ☐ CDC Contractor ☐ Internet Receiving organization name: Click here to enter text. Receiving organizations type: If there are more than one receiving organization types, please list here: Click here to enter text.
INTERNET AND SOCIAL MEDIA
Internet: Did this event involve Internet ads? Website URL: Click here to enter text.
Number of Internet Ads Placed: Click here to enter text. Internet Ad Impressions: Click here to enter text. Clicks from Online Advertisements Click here to enter text.
Social Media: Did this event involve social media? If yes, please check all social media platforms used: ☐ Blogs ☐ Twitter ☐ Facebook ☐ YouTube ☐ Flickr ☐ Instagram ☐ Other If other, explain: Please provide as much detail as possible.
Facebook Page Name: Date: Click here to enter a date. Post: Click here to enter text. Likes: Click here to enter text. Shares: Click here to enter text. Comments: Click here to enter text.	Twitter Account Name: Date: Click here to enter a date. Number of Tweets: Click here to enter text. Number of Tweets on hashtag (#): Click here to enter text.				Blog or Other Social Media Page Name: Date: Click here to enter a date. Post: Click here to enter text. Likes: Click here to enter text. Shares: Click here to enter text. Comments: Click here to enter text.
MEDIA
Was there media activity? If there were multiple media activities, please list individually: Media Activity # 1 Begin date: Click here to enter a date. End date: Click here to enter a date. What type of media? Please select all media outlets that apply: ☐ Internet ☐ TV ☐ Print ☐ Out-of-home ☐ Radio ☐ Other If other, explain: Click here to enter text. Media Activity # 2 Begin date: Click here to enter a date. End date: Click here to enter a date. What type of media? Please select all media outlets that apply: ☐ Internet ☐ TV ☐ Print ☐ Out-of-home ☐ Radio ☐ Other If other, explain: Please provide as much detail as possible. Media Activity # 3 Begin date: Click here to enter a date. End date: Click here to enter a date. What type of media? Please select all media outlets that apply: ☐ Internet ☐ TV ☐ Print ☐ Out-of-home ☐ Radio ☐ Other If other, explain: Click here to enter text.
Media Value Was the media donated? Was the media paid? What is the media value? Click here to enter text.
Overall Comments: Click here to enter text.

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