ATSDR Health Education Activity Tracking (HEAT) Form

Attachment 4a. ATSDR Health Education Activity Tracking (HEAT) Form (Word)

Form Approved OMB Control Number: 0923-0057 Expiration Date: 07/31/2020 ATSDR estimates the average public reporting burden for this collection of information as 3 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-0057).
Health Education Details
Actual Start Date:	[date field]
Complete Date:	[date field]
Description:	[free text field]
Training Details
Delivery Method:	[drop-down options]: In-person training Online training Paper material distribution Web-based material distribution Television, radio, or newspaper
Community Intervention Initiative:	[drop-down options]: Brownfields Other
Direct Training Provider:	[drop-down options]: COOP Region Health Educator Health Assessors ATSDR HQ Health Assessors/ Health Educator Other
HE/CI Training Method:	[drop-down options]: One-on-One Training Small Group (1-10) Training Large Group (>10) Training Webinar / Conference Call Public Meeting or Public Availability Session Mini Grant Exhibit Booth Local, State or National Conference Train the Trainer None of the Above
Participation Evaluation
Number of Community Participants	[number field]
Number of People Understanding Health Risk	[number field]
Number of People Understanding Pathways	[number field]
Number of People Knowing Contact for Concerns	[number field]
Materials Evaluation
Were Materials Distributed?	[selection] Yes or No
Number of People Receiving Materials	[number field]
Number of People Understanding Materials	[number field]
Number of Materials Distributed Electronically	[number field]
Number of Materials Distributed Non-Electronically	[number field]