Health Education (screenshots) with COVID-19 question

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﴿.

ATSDR Health Education Activity Tracking
HEAT Site Information

Title *

State
Please select a value...

Cost Recovery #

Site or Activity Name *

HEAT Activities Information

Site Related Education?
Site Related Education?

Was activity completed by
cooperative agreement
partner? ﴾If yes, check box﴿
Cooperative Agreement
Partner

Is activity related to the
Choose Safe Places for Early
Childcare and Education
program? ﴾If yes, check box﴿

Is activity related to COVID‐
19? ﴾If yes, check box﴿

Choose Safe Places
program

Date Started *

Date Completed *

Educator Type *

Educator Name

Coop Partner

Evaluation Method *
None of the above

HE/CI Delivery Method *
None of the above

# of Community Participants *

# Understanding Health Risk

# Understanding Pathways

# Knowing Contact for Concerns

Brief Description of Activity *

Were Materials Distributed?

# Receiving Materials

Were Materials
Distributed?
Link
Type the Web address:

Text to display:

Attachments

Save

Cancel

# Understanding Materials