Coordinated School Health Success Story
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1
. County/District:
County/District:
2
. Date:
MM
DD
YYYY
MM/DD/YYYY
Date: MM/DD/YYYY Month
/
Day
/
Year
3
. Initiative Level:
Initiative Level:
District Level Initiative
School Level Initiative
School Name (if applicable):
4
. Contact Information:
Contact Information:
Name:
Email Address:
Phone Number:
5
. Name of Initiative, Activity, or Event:
Name of Initiative, Activity, or Event:
6
. CSH Components addressed (check all that apply):
CSH Components addressed (check all that apply):
Health Education
Employee Wellness
Parent/Community Involvement
School Health Services
Counseling, Psychological, and Social Services
Healthy School Nutrition
Physical Education/Activity
Healthy School Environment
All CSH Components
7
. Total Cost of Initiative:
Total Cost of Initiative:
Internal Funding $
Outside Funding $
8
. Please indicate your Outside Funding Source if applicable.
Please indicate your Outside Funding Source if applicable.
9
. Was an evaluation of the initiative conducted?
Was an evaluation of the initiative conducted?
Yes
No
If yes, please describe.
10
. What population did the initiative reach as a result of this successs? (Check all that apply).
What population did the initiative reach as a result of this successs? (Check all that apply).
Elementary School
Middle School
High School
Parents
District/School Administration
Youth in High-Risk Situations
School Staff
Family/Community
Other (please specify)
11
. Please list the number of participants in each category:
Please list the number of participants in each category:
Students
Staff
Teachers
Administrators
Food Service
Health Educators
Parents/Families
Nurses
Community
Others
12
. Please provide some background information about this initiative:
Please provide some background information about this initiative:
13
. Please describe the implementation process of this initiative (explain so others may replicate):
Please describe the implementation process of this initiative (explain so others may replicate):
14
. Please describe the impact or outcomes of this initiative:
Please describe the impact or outcomes of this initiative:
15
. Are any follow-up activities planned? If so, what?
Are any follow-up activities planned? If so, what?
16
. Tips/Recommendations/Comments:
Tips/Recommendations/Comments:
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