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In-Person Event Reporting Form
portaourp
2023-05-01T09:40:57-05:00
In-Person Event Reporting Form
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Step
1
of 3
Event Name/Title
*
Event Start Date
*
Date
Time
Event End Date
*
Date
Time
Time Zone
*
EST
CST
MST
PST
HST
Event Venue
*
Venue Type
*
Church
Community Center
Community Event
DV Corporate Partner Site
FQHC Site
Health-Related Venue e.g. Hospital
Hotel / Conference Center
HPO Site
Large Fair / Event / Festival
Library
Non-Event Venue
Office Building
Parking Lot / Retail Location
Residence
School
Senior Center
Sports Facility
Street
Other
Please select audience for this activity
*
Adults
Youth (under age of 18)
Estimated number of adult reached
*
Estimated number of youth reached
*
Audience Type
*
Participant
Researcher
Primary Purpose of Activity
*
Check all that apply.
Participant Recruitment
Participant Retention
Type of Activity
*
Check all that apply.
Outreach: Food distribution, flyer distribution, radio shows
Education: Workshop, presentation, seminar
Engagement: Festivals, health fairs
Enrollment: event specific for account creation and enrollment, Journey Bus event
Listening Sessions: covenings
Other
Please describe "Other"
*
Number of Participants Outreached To
*
Number of participants at outreach event that received flyers, handouts, or other information related to AoU
Number of Participants Educated
*
Number of participants at education event
Number of Participants Engaged
*
Number of participants at engagement event
Next
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
Please list partners here:
*
Please list all partners you worked with, including HPOs or community organizations
Attendees/ Audience Size
*
Type of Activity
*
Non-Digital
Non-Digital Activities
*
Booth/Exhibit
Print Distribution/Advertising
Speaker/Presentation
Topical Session/Workshop
Other - Non-Digital
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Next
Number of Assets Disseminated
*
Examples include flyers, brochures, etc.
Type of Asset most widely disseminated (describe)
Examples include AoU flyer, FAQ sheet, AoU Brochure, etc.
Upload Photos From This Event
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You can upload up to 30 files.
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