In-Person Event Reporting Form

- Step 1 of 3

Event Name/Title *

Event Description *

Event Start Date *

Date

Time

Event End Date *

Date

Time

Time Zone *

Event Venue *

Venue / Event Address *

Address Line 1

Address Line 2

City

State

Zip Code

Venue Type *

Audience Type *

Primary Purpose of Activity *

Check all that apply.

Participant Recruitment
Participant Retention

Did This Activity Focus on Education or Engagement? *

Check all that apply.

Education
Engagement

Number of Participants Educated *

Number of Participants Engaged *

Focus *

A primary focus is an activity dedicated to the All of Us program. An activity with a secondary focus supplements All of Us messaging with another topic.

Target / Primary Population *

Check all that apply.

Race: Black/African American
Race: Hispanic/Latino/Spanish
Race: Asian
Race: Middle Eastern/North African
Race: American Indian/Alaska Native
Race: Native Hawaiian/Other Pacific Islander
Race: White
Age: Under 18
Age: 18-24
Age: 25-24
Age: 34-44
Age: 45-54
Age: 55-64
Age: 65+
Age: Older Adults
Income: Low
Income: Medium
Income: High
Gender: Women
Gender: Sexual and Gender Minorities (LGBTQ)
Geo: Rural
People with Disabilities
Healthcare Providers
Researchers
Other

Please Specify "Other" *

If You Had Partners for This Event, Please Select Them

Check all that apply.

Direct Volunteer (DV) Site Partners
The Journey Bus or Mobile Engagement Asset
Health Provider Organization (HPO) Partners
Local Chapter / Organization / University
Local Businesses
Local Media Outlets
CPGI (Community and Provider Gateway Initiative)
National Community Engagement Partner - Asian Health Coalition
Faith-Based Organizations
NNLM (National Library of Medicine)
Other

If You Collaborated with All of Us HPOs, Please Select From the Following List:

Wisconsin - Marshfield Clinic Research Institute
Wisconsin - Blood Center of Wisconsin, Milwaukee
Wisconsin - University of Wisconsin School of Medicine and Public Health in Madison
California Precision Medicine Consortium - University of California San Diego (lead)
California Precision Medicine Consortium - Cedars-Sinai Medical Center, Los Angeles
California Precision Medicine Consortium - San Diego Blood Bank
California Precision Medicine Consortium - University of California, Davis
California Precision Medicine Consortium - University of California, Irvine
California Precision Medicine Consortium - University of California, San Francisco
California Precision Medicine Consortium - University of Southern California, Los Angeles
Illinois Precision Medicine Consortium - Northwestern University, Chicago
Illinois Precision Medicine Consortium - University of Chicago
Illinois Precision Medicine Consortium - University of Illinois at Chicago
Illinois Precision Medicine Consortium - North Shore University Health System, Chicago
Illinois Precision Medicine Consortium - Rush University Medical Center, Chicago
New England - Partners HealthCare System (lead) and its founding hospitals, Brigham and Women's Hospital and Massachusetts General Hospital
New England - Boston Medical Center
New England - Newton-Wellesley Hospital
New York City Precision Medicine Consortium - Columbia University Medical Center, New York City (lead)
New York City Precision Medicine Consortium - NYC Health + Hospitals/Harlem, New York City
New York City Precision Medicine Consortium - New York-Presbyterian, New York City
New York City Precision Medicine Consortium - Weill Cornell Medicine, New York City, New York City
Southern All of Us Network - University of Alabama at Birmingham (UAB)
Southern All of Us Network - Cooper Green Mercy Health Services, Birmingham, Alabama
Southern All of Us Network - Huntsville Hospital, Alabama
Southern All of Us Network - Louisiana State University Health Science Center, New Orleans
Southern All of Us Network - Tulane Medical Center, New Orleans
Southern All of Us Network - Tuskegee University, Alabama
Southern All of Us Network - UAB Hospital, Birmingham, Alabama
Southern All of Us Network - UAB School of Medicine's Montgomery Internal Medicine and Selma Family Medicine programs, Birmingham, Alabama
Southern All of Us Network - University of Mississippi Medical Center, Jackson
Southern All of Us Network - University of South Alabama Health System, Mobile
Southern All of Us Network - University Medical Center, Tuscaloosa, Alabama
SouthEast Enrollment Center - University of Miami Miller School of Medicine, Florida
SouthEast Enrollment Center - Emory University, Atlanta
SouthEast Enrollment Center - Morehouse School of Medicine, Atlanta
SouthEast Enrollment Center - OneFlorida Clinical Research Consortium led by the University of Florida in Gainesville
Trans-American Consortium for the Health Care Systems Research Network - Henry Form Health System, Detroit (lead)
Trans-American Consortium for the Health Care Systems Research Network - Baylor Scott and White Health, Dallas
Trans-American Consortium for the Health Care Systems Research Network - Spectrum Health, Grand Rapids, Michigan
Trans-American Consortium for the Health Care Systems Research Network - Essentia Institute of Rural Health, Minnesota
Trans-American Consortium for the Health Care Systems Research Network - Reliant Medical Group, Massachusetts
University of Arizona, Tucson - Banner Health, Phoenix
University of Pittsburgh at Pittsburgh
Federally Qualified Health Center - Cherokee Health Systems, Knoxville, Tennessee
Federally Qualified Health Center - Community Health Center, Inc., Middletown, Connecticut
Federally Qualified Health Center - Eau Claire Cooperative Health Center, Columbia, South Carolina
Federally Qualified Health Center - HRHCare, Peekskill, New York
Federally Qualified Health Center - Jackson-Hinds Comprehensive Health Center, Jackson, Mississippi
Federally Qualified Health Center - San Ysidro Health, San Ysidro, California
Vanderbilt University
VA Medical Centers

Please Select What Activity Was Used to Engage Community Members *

Check all that apply.

Booth / Exhibit
Print Distribution / Advertising
Speaker / Presentation
Topical Session / Workshop
Other-Non-Digital

Booth / Exhibit Attendees *

Booth / Exhibit Visits *

Booth / Exhibit Non-Digital Engagements *

Number of Print Distribution / Advertising Distributed *

Speaker / Presentation Attendees *

Speaker / Presentation Non-Digital Engagements *

Session / Workshop Attendees *

Session / Workshop Non-Digital Engagements *

Please Specify "Other" *

Brief Description of Event.

"Other" Attendees *

"Other" Non-Digital Engagements *

Calls To Action *

Check all that apply.

Bitly Link/QR Code
Vanity URL
Download App
Provide Email Address

Please List the Bitly/Tiny URL Used *

Total Bitly Clicks / Scans *

Please List the Vanity URL Used *

Total Vanity URL Clicks / Referrals *

Total Number of App Referrals *

Total Number of Emails Collected *

Which of the Following Describes Attributes of Your Event?

Check all that apply.

Community Resource Program (CRP)
Distributed Giveaways (non-printed, branded materials like t-shirts/water bottles)
"Elevate" Campaign
Involved Elected Officials
Provider Event with CME/CE Credit
Provider Event without CME/CE credit
Virtual Ambassador Program (VAP)

Total Items Distributed *

How Many Attendees Received CME/CE Credit? *

What Elements of Your Activity Were Successful? *

What Elements of Your Activity Were Not Successful? *

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