ATSDR SoilSHOP Form

APPLETREE Performance Measures

Att4h soilSHOP Form 20200325m

ATSDR SoilSHOPS Form

OMB: 0923-0057

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Attachment 4h. ATSDR SoilSHOP Form


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Form Approved

OMB No. 0923-0057

Exp. Date 07/31/2020


ATSDR estimates the average public reporting burden for this collection of information as 7 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).

ATSDR SoilSHOP Form

Directions: Complete form within two weeks of SoilSHOP event. Submit via email to Elisha Hall, nyu2@cdc.gov

Basics:

Date of Event:

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Venue:

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City:

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State:

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Was APPLETREE involved?

Yes

No

Was ATSDR involved?

Yes

No

POC(s)

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Flyer/website link

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What partners were involved (list organization/agency names, no individual names, no acronyms)?

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What resources were used from partners (select all that apply)?

XRF

Office supplies

Tables/chairs/tents

Venue/booth space

Signage/printed materials

Other, please specify:

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What activities were delivered at the event (select all that apply)?

Soil lead screening

Blood lead screening

One-on-one health education

Provision of health education materials (handouts, brochure, etc)

Referrals for additional/other related health services

Children's activities

Other, please specify:

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What outputs were produced? Outputs are the direct results of activities.



# of estimated attendees (including passersby)

# individuals receiving health education consultations

# of individuals who received soil screening

# of total samples screened

# of samples with results >100 mg/kg

# samples with results >400 mg/kg

# referrals provided

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If there were high soil screenings, how were they addressed? (If n/a, skip question)

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Discuss key achievements/highlights of this event (e.g. new partner interest, high participation rate)?

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Optional Information:

What worked well during this event (e.g. planning process, partnership, etc.….)?

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What didn’t work well during this event?

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What marketing tools were used for this event? Were they effective?

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Event Images (if available):

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