ATSDR SoilSHOP Form

Attachment 4h. ATSDR SoilSHOP Form

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:	Click or tap here to enter text.	Venue:	Click or tap here to enter text.
City:	Click or tap here to enter text.	State:	Click or tap here to enter text.
Was APPLETREE involved?	Yes No	Was ATSDR involved?	Yes No
POC(s)	Click or tap here to enter text.	Flyer/website link	Click or tap here to enter text.

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

Click or tap here to enter text.

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:

______________________________________

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:

________________________________________________

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
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.

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)?

Click or tap here to enter text.

Optional Information:

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

Click or tap here to enter text.

What didn’t work well during this event?

Click or tap here to enter text.

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

Click or tap here to enter text.

Event Images (if available):