BEACON Monthly Reporting Form

Organization Name *

Month and Year* *

This should be for the month and year you are reporting on. If you are submitting a report late, please ensure you are putting the correct month and year.

Number of Health Education Events *

Number of Health Fair Type Events *

Number of Outreach Events *

Estimated Total Attendance for All Events *

Estimated Number of Attendees Recieving Health Navigation Support *

Examples include: staff members assisting to make appointments, staff members answering questions about insurance and benefits, assistance utilizing digital health tools such as MyChart, etc.

Number of Appointments and Referrals Made This Month *

Organization use for

Follow Ups This Month *

Please use this space to describe anything else or discuss any other activities for the month