Activity Report: Community Education Outreach Report - WomenHeart: The National Coalition for Women with Heart Disease

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Activity Report: Community Education Outreach Report

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Thank you for filling out the Community Education Outreach Report. We appreciate your time and efforts on behalf on WomenHeart and its mission to improve the health of women.

If you need assistance, please contact Khaleelah Hardie at khardie@womenheart.org.

If this report contains timely information that requires immediate action, please contact WomenHeart at 202-728-7199.

If yes, please list the names and relationship for each person
First Name *		Last Name *
City *		State *Two letter state abbr.
Symposium *		Did you conduct these activities with any one else? *	Yes No

First name of participant		Last name of participant
Relationship
First name of participant 2		Last name of participant 2
Relationship of participant 2
First name of participant 3		Last name of participant 3
Relationship of participant 3
If a non-WomenHeart Champion participated, please attach her information so we may thank them
*

Report Information

What type of outreach did you participate in? *
Please go to the section reflecting your activity
Please only fill out the type of activity you were engaged in. Thanks!
*

Option 1: Health Fair

Name of Event
Date of event (mm/dd/yyyy)		Event Sponsor
Event Location (address)		Event city and state
Health Fair Event contact name
Health Fair Event Contact phone		Health Fair Event Contact email
Health Fair Audience size
Primary audience demographic - please check all that apply	African American/Black Native American/Alaska Native Caucasian/White Asian Hispanic/Latina(o) Female Male
How did you learn about this event?
If other, please specify
Total hours spent on event (Include pay and travel)		Fraction of hour spent on event
Materials distributed (check all that apply)	Get Smart brochure WomenHeart brochure Living Well with Heart Disease brochure Heart Health & Diabetes brochure Hospital Alliance brochure English bookmarks Spanish bookmarks Prescription Pads 911 materials HeartScarves Join Now cards Red Bags of Courage Para La Mujer Hispana Red Bag of courage
If other please specify
Would you have benefited from having additional educational materials available at this event?		If so, what materials would have been beneficial?
Is this a recurring event?		If so, are there opportunities to speak to a larger audience that WomenHeart could pursue?
Whom should we contact to pursue this opportunity?Please provide name, title, email and phone
*

Option 2: Invidivual Speaking Engagement

Name of Event
Date of event (mm/dd/yyyy)		Event sponsor hospital or business name
Event location		Event city and state
Speaking Engagement Contact name		Speaking Engagement Contact phone
Speaking Engagement Contact email		Speaking Engagement Audience size
Primary Audience Demographic (please check all that apply)	African American/Black Native American/Alaska Native Caucasian/White Hispanic/Latino Hispanic/Latina(o) Asian Female Male
How did you hear about this event?
If other, please specify		Total hours spent on event Include prep and travel
Materials distributed	Get Smart brochure WomenHeart brochure Living Well with Heart Disease brochure Heart Health & Diabetes brochure Hospital Alliance brochure English bookmarks Spanish bookmarks Prescription Pads 911 Materials HeartScarves Join Now Cards Red Bags of Courage Para La Mujer Hispana Red Bag of courage
If other, please specify
WomenHeart Resources Used	Exhibit display Tablecloth and/or runner Soledad O'Brian DVD Support Network DVD	Presentation topic
How much time were you provided to speak?How long (in minutes) was your presentation?
*

Option 3: Panel Discussion

Name of Panel Event		Date of Panel Event (mm/dd/yyyy)
Event sponsor hospital or business
Panel event location		Panel event city and state
Event contact phone		Event contact email
Event contact phone		Audience size
Primary panel event demographic (please check all that apply)	African American/Black Native American/Alaska Native Caucasian/White Hispanic/Latina(o) Asian Female Male
How did you learn about this event?
If other, please specify
Total hours spent on this panel event		Fraction of hour spent on panel event
Materials distributed on panel event	Get Smart brochure WomenHeart brochure Living Well with Heart Disease brochure Heart Health & Diabetes brochure English bookmarks Spanish bookmarks Prescription Pads 911 Materials HeartScarves Join Now Cards Red Bags of Courage Para La Mujer Hispana Red Bag of courage
If other, please specify
WomenHeart Resources Used
Presentation topic		How much time were you provided to speak
*

Option 4: Media Event

What type of media event did you participate in?
Date of interview (mm/dd/yyyy)		Name of media outlet
Total hours spent on this event Include prep and travel		Fraction of an hour spent on event
Interview topic
How did you learn about this opportunity?
If other, please specify
Please provide information where the interview can be located (time, network, publication)
If you can upload the event, please do so
*

Please share your event experience with us

How useful was WomenHeart staff in preparing you for this event?		Did you book another event while participating?
Would you recomment that WomenHeart participate in this event next year?		Explain
Would you like WomenHeart to send an appreciation letter to the event sponsor?
if so, please provide the mailing address below

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