Chapter/District Outreach Reporting

	Thank you for completing this important information about the
	way you are conducting outreach for the National ALS Registry.
	Please submit a form monthly for your chapter or district.
	Org Code
	District or Chapter Name
	Clinic, Support Group, Seminar, Other group activities
	Kaye, Wendy (ATSDR/DTHHS/EHSB) (CTR): Indicate if a clinic, support group, seminar, or other group activities Activity	Date	# Registry information kits distributed	# people talked to about the Registry	# people helped sign-up for the Registry	City and State
Total
	Social Media and local mailings (e.g., tweet, email blast, newsletter)
	Activity	Date	#	City and State
Total
	Fundraising event (e.g., walk, golf tournament)
	Type of event	Date	# attendees	Materials distributed or displayed	City and State
Total
	Outreach calls made where the Registry was discussed
	# calls	City and State
Total