Injury Prevention & Education Activity Summary FY12
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1. Default Section
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. In order to meet CTRAC requirements, each agency/facility is required to participate in at least one RAC sanctioned prevention activity annually and submit documentation of such. A RAC sanctioned event is any event that takes place in the TSA-L region that your agency is directly involved in, and it specifically involves injury prevention activities. Please submit the form below in order to document participation.
In order to meet CTRAC requirements, each agency/facility is required to participate in at least one RAC sanctioned prevention activity annually and submit documentation of such. A RAC sanctioned event is any event that takes place in the TSA-L region that your agency is directly involved in, and it specifically involves injury prevention activities. Please submit the form below in order to document participation.
Name:
Agency:
Email Address:
Phone Number:
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. Event Name and Description:
Event Name and Description:
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. Date of Event (List multiple dates for on-going or repeat events):
Date of Event (List multiple dates for on-going or repeat events):
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. Location of Event (City/Site/Agency):
Location of Event (City/Site/Agency):
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. Participating Agencies:
Participating Agencies:
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. Target Audience (ie- Community, EMS, Nurses, Children, Elderly):
Target Audience (ie- Community, EMS, Nurses, Children, Elderly):
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. Estimated Number in Attendence:
Estimated Number in Attendence:
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. Total Number of Staff Hours--Hours of Involvement (# of staff involved multiplied by # of hours, including set up and travel)
Total Number of Staff Hours--Hours of Involvement (# of staff involved multiplied by # of hours, including set up and travel)
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