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  3. Initial Assessment form for Prevention Outreach Activities-Draft

Initial Assessment form for Prevention Outreach Activities-Draft

Fax to: Casetta Simmons at 404-498-0079 or email to crrl@cdc.gov with a cc to your technical advisor. click here for printer friendly version.

Date faxed to state personnel: _____________

Date state responded: __________________

Description of previous data clearance request (Casetta will provide):
________________________________________________________________

Date activity was completed: __________________

Name (HSEES coordinator): _____________________________
City: ____________________ State: _________________

Phone Number: ___________________________

Actual Audience Number (i.e., the number of copies distributed, the attendees at the conference session, or the number of visitors at a website): ____________________

Feed-back/Success Story (A brief description of how the activity went. Please write clearly):

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Future Plans:

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Thanks and have a wonderful day!

------------------------ For Official Use Only -----------------------------------

Date received: ______________
Data Clearance Request # ___________ Follow-up # _______________
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