ATSDR Health Education Activity Tracking (HEAT) Form

[ATSDR] APPLETREE Performance Measures

Att4a1 ATSDR HE Form ( WORD) 08212023

ATSDR Health Education Activity Tracking (HEAT) Form

OMB: 0923-0057

Document [docx]
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ATSDR Health Education Form ARMSS (WORD)

Form Approved

OMB No. 0923-0057

Exp. Date 09/30/2023



ATSDR estimates the average public reporting burden for this collection of information as 4 minutes 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 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 H21-8, Atlanta, Georgia 30333; ATTN: PRA (0923-0057).

Create Activity Form (Screen 1)

Activity Type

Dropdown

Requested Source

Dropdown

Requested Source Details (Optional)

Fill in

Request Description

Fill in

Source POC (Optional)

Fill in

Coop Program

Yes/No

Jurisdiction

Dropdown

Choose Safe Places for Early Care and Education

Yes/No

Activity Name

Fill in

Section

Dropdown

Team/Region

Dropdown

Current POC

Dropdown

Planned Start Date

Select date

Notes (Optional)

Fill in



Edit Health Education (Screen 2)

Site Info

Attach to site/Manage site association

Documents

Attach/Upload any additional documents



Actual Start Date

Select date

Complete Date

Select date

Description

Fill in

Training Details


Delivery Method

Dropdown

Community Intervention Initiative

Dropdown

Direct Training Provider

HE/CI Training Method

Participant Evaluation


Number of Community Participants

Fill in

Number of People Understanding Health Risk

Fill in

Number of People Understanding Pathways

Fill in

Number of People Knowing Contact for Concerns

Fill in

Materials Evaluation


Were material distributed

Yes/No

Number of people receiving materials

Fill in

Number of people understanding materials

Fill in

Number of materials distributed electronically

Fill in

Number of materials distributed non-electronically

Fill in

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCrum, Kendall (ATSDR/OAD/OCDAPS)
File Modified0000-00-00
File Created2023-09-20

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