Att4a1 ATSDR HE Form ( WORD) 08212023

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