3 Substudy AlabamaOutreach Activity/Tracking

OMB # 0925-0701

Expiration Date: 07/31/2017

A labama Safe Sleep Outreach Project
Mini-Grantee Activity Tracking Form

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0701). Do not return the completed form to this address.

NOTE: Please be advised that the Safe Sleep Outreach Project and the data collection is sponsored by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The purpose of collecting the information required on this form is for mini-grantees to track training events hosted under mini-grant awards. The completed forms will be used to count the number of events hosted by each mini-grantee, the number and demographic of attendees at each event, and whether the event was an awareness or educational session. All personal information will be stored in a locked cabinet.

Organization:	Click or tap here to enter text.
Date of Report: (Month / Day / Year)	Click or tap here to enter text.
Contact Person:	Click or tap here to enter text.
Telephone:	Click or tap here to enter text.
Email:	Click or tap here to enter text.
Address:	Click or tap here to enter text.

1. Which geographic area did the project activity serve? (county and zip code for each area required)

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2. Please describe all of the SIDS/safe infant sleep outreach activities that you conducted during this grant cycle of January 8, 2016 through July 31, 2016. Be sure to be specific. Please use additional pages as needed.

• Total Number of Events: Click or tap here to enter text.

• Total Number of Participants Who Attended Events: Click or tap here to enter text.

Activity	Description	Event Date	Number of Attendees	Activity Audience	Encounter: Awareness vs. Educational
EX. Safety Baby Shower	Desha County Health Unit representatives partnered with church officials from First Baptist Church Day Care Center in McGehee to train parents and child care providers on safe infant sleep using the Safe to Sleep® educational video and print materials. The Bruce Family Endowment provided a supplementary in-kind donation for this education initiative, which covered meal expenses for training participants.	1/9/2016	35	Expecting mothers New parents Grandparents Church members	Educational
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3. Which safe infant sleep messages were the most challenging for your training participants? Please explain.

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4. What aspects of this project worked well and would you do again to make your outreach successful? Please explain.

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5. Do you feel you have the information and resources you need to raise awareness of SIDS and promote safe infant sleep in your community?

☐ Yes

☐ No, what types of information or resources would be most helpful to you?

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All Activity Tracker forms must be turned in at the Closing Meeting on August 5, 2016.

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