FASD Work Plan

Form Approved
OMB No. 0902-XXXX
Exp.: XX/XX/20XX

Fetal Alcohol Spectrum Disorders
Regional Education and Awareness Liaisons

Improving health outcomes for infants and children diagnosed with one of the FASDs
by addressing stigma and bias and increasing early identification.

Name: ______________________________________________________________________ Date: ________________

Region: ____________________________________________

As the FASD champion for Region ____ of the American Academy of Pediatrics (AAP), I will take part in the following activities to support issues related to FASD during 2016:

FASD Champion Metric: FASD Champions will submit a work plan including specific aims and measures for achieving progress. At the end of the year, FASD Champions will provide a written summary/update on progress made towards work plan activities.

2016 Work Plan Submission Date:

FASD Champion Metric: FASD Champions will participate on Regional Network trainings/conference calls/webinars 1 times per year.

Dates:

1. _______________________________ Attended Yes ⎕ No ⎕

Details on method, mode and frequency of contact and planned collaborative efforts:

Other Person(s) Involved:

FASD Champion Metric: FASD Champions will educate pediatric clinicians in their respective regions regarding FASD.

Activity 1:
Date:
Audience:

Person(s) Involved:

Activity Details:

Activity 2:
Date:
Audience:

Person(s) Involved:

Activity Details:

*More activities can be listed on the back of this page as necessary

Other FASD Champion Activities.

Activity:
Date:
Person(s) Involved:

Activity Details:

Activity:
Date:
Person(s) Involved:

Activity Details:

Activity:
Date:
Person(s) Involved:

Activity Details:

The public reporting burden of this collection of information is estimated to average 20 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: PRA (XXXX-XXXX).