Success Story Form (screenshots)

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Form Approved
OMB Control Number: 0923‐0057
Expiration Date: 07/31/2020Please update the exp. date.
ATSDR estimates the average public reporting burden for this collection of information as 1 hour per 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 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 Information Collection Review Office, 1600 Clifton Road NE, MS D‐74, Atlanta, Georgia 30333; ATTN: PRA ﴾0923‐0057﴿

ATSDR Success Story Form
Project or Site Name *

Is activity related to COVID‐19?
﴾If yes, check box﴿

Attachments

Link

Please include photos!

Type the Web address:

Text to display:

Add a relevant link to the site or project, if applicable.

APPLETREE? *

Choose Safe Places Program

Yes

Please select a value...

No
Is the success story from an APPLETREE partner?

Is this a success story for the Choose Safe Places for Early Care and Education
(CSPECE) program?

City *

State *
Please select a value...

POC *

List who should be contacted for further information about the success story.

Brief Summary *
In 1‐3 sentences, give a brief summary of the success story.

Background
In 140‐250 words, describe relevant background of site or project. Include dates and who was involved.

Intervention
In 140‐250 words, describe the solution, intervention, or action that was taken.

Accomplishments
In 140‐250 words, describe the impacts, outcomes, and results of the actions that were taken.

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