ATSDR SoilSHOP Form

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 H21-8, Atlanta, Georgia 30333; ATTN: PRA (0923-0057).

Form Approved

OMB No. 0923-0057

Exp. Date 09/30/2023

ATSDR soilSHOP Form

Directions: Complete form within three weeks of soilSHOP event. Please type over the example language and checkboxes.

Submit via email to Laurel Berman, fjq0@cdc.gov

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.
How was APPLETREE involved? (Select all that apply)				How was ATSDR involved? (Select all that apply)
Planning Outreach Partnership building Partner training		One on one health education Event support Event host Other: ______________		Planning Outreach Partnership building Partner training		One on one health education Event support Event host Other: ____________
Event POC(s) Name: & Email:			Click or tap here to enter text.	Reporting POC(s) Name & Email:			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 acronyms. Do NOT include individual names.

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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

Staff time

Other, please specify: ______________________________________

What activities were delivered at the event? Select all that apply.

Soil lead screening

Blood lead screening

Provision of health education materials (trifold, handout, etc)

One-on-one health education

Referrals for additional/other related health services

Children's activities

Other, please specify: ________________________________________________

What were the direct results of the event?

Complete as many fields below as possible. If you did not collect data, please indicate “did not collect data” in response field so it is clear that the data is missing rather than zero.

# of estimated attendees (including passersby)	Click or tap here to enter text.
# health education materials distributed at event	Click or tap here to enter text.
# of individuals receiving one-on-one health education consultations	Click or tap here to enter text.
# of individuals who received soil screening	Click or tap here to enter text.
# of total soil samples screened for lead	Click or tap here to enter text.
# of soil samples with lead results >100 mg/kg	Click or tap here to enter text.
# soil samples with lead results >400 mg/kg	Click or tap here to enter text.
# referrals provided	Click or tap here to enter text.

If there were soil screenings with high lead levels, how were they addressed? If n/a, skip.

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Describe any key achievements/highlights/successes of this event. If possible, include 1-2 quotes from participants or staff that show the event’s importance or highlight the success.

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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?

Event Images (if available). Please submit photo waivers and add citations, e.g., “Image taken by ATSDR, 202x” or “Image taken by An Doe, 202x, who provided an emailed/written permission to use the image.” Please paste over the example images below and add citations: