0920-0840 LGBTQ Inclusivity Toolkit Demonstration Project Monthly

Form Approved

OMB No. 0920-0840

Expiration Date: 07/31/2024

LGBTQ Inclusivity Toolkit Demonstration Project

Monthly Report Form

Public reporting burden of 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 current 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 (0920-0840).

LGBTQ Inclusivity Toolkit Demonstration Project

Monthly Report Form

This worksheet is intended to support your district as your team works towards adopting the LGBTQ inclusivity strategies that you select after reviewing the toolkit. LGBTQ stands for lesbian, gay, bisexual, transgender, or queer/questioning. We have filled in each strategy and associated steps that you shared with us as part of your action plan. Please indicate your progress with each step this month and share any events or activities that took place.

Please complete this report and submit it to [email protected] by the 15^th of each month (for example, please submit the February report by March 15^th).

Name of District:
Month:
Strategy: These are the strategies you listed in your district action plan.	Steps to Complete the Strategy These are the steps that you listed to complete each strategy in your district action plan.	Progress this month Please indicate your progress with each step this month.	Notes Please tell us about your completed activities, successes, and challenges during the month. If there is anything else you’d like to record, please add any notes here.
Strategy 1:	Step 1	Have not started Worked on but not finished Finished this month Already finished before this month
	Step 2	Have not started Worked on but not finished Finished this month Already finished before this month
	Step 3	Have not started Worked on but not finished Finished this month Already finished before this month
	Step 4	Have not started Worked on but not finished Finished this month Already finished before this month
	Step 5	Have not started Worked on but not finished Finished this month Already finished before this month
Strategy 2:	Step 1	Have not started Worked on but not finished Finished this month Already finished before this month
	Step 2	Have not started Worked on but not finished Finished this month Already finished before this month
	Step 3	Have not started Worked on but not finished Finished this month Already finished before this month
	Step 4	Have not started Worked on but not finished Finished this month Already finished before this month
	Step 5	Have not started Worked on but not finished Finished this month Already finished before this month
Strategy 3:	Step 1	Have not started Worked on but not finished Finished this month Already finished before this month
	Step 2	Have not started Worked on but not finished Finished this month Already finished before this month
	Step 3	Have not started Worked on but not finished Finished this month Already finished before this month
	Step 4	Have not started Worked on but not finished Finished this month Already finished before this month
	Step 5	Have not started Worked on but not finished Finished this month Already finished before this month
Strategy 4:	Step 1	Have not started Worked on but not finished Finished this month Already finished before this month
	Step 2	Have not started Worked on but not finished Finished this month Already finished before this month
	Step 3	Have not started Worked on but not finished Finished this month Already finished before this month
	Step 4	Have not started Worked on but not finished Finished this month Already finished before this month
	Step 5	Have not started Worked on but not finished Finished this month Already finished before this month

Did your district host any events or activities related to LGBTQ inclusivity this month (for example, planning meetings, GSA or other club meetings, events, professional development trainings, or other)? If so, please list each activity and the number of people that attended each activity below. Please do not include names of attendees or any other identifying information.

Name of event	Number of attendees

Thank you for taking the time to fill out this monthly report! Your ICF coordinator will follow up with you to schedule a monthly call.