Coordinated School Health Success Story

1. County/District:
2. Date:
3. Initiative Level:
4. Contact Information:
5. Name of Initiative, Activity, or Event:
6. CSH Components addressed (check all that apply):
7. Total Cost of Initiative:
8. Please indicate your Outside Funding Source if applicable.
9. Was an evaluation of the initiative conducted?
10. What population did the initiative reach as a result of this successs? (Check all that apply).
11. Please list the number of participants in each category:
12. Please provide some background information about this initiative:
13. Please describe the implementation process of this initiative (explain so others may replicate):
14. Please describe the impact or outcomes of this initiative:
15. Are any follow-up activities planned? If so, what?
16. Tips/Recommendations/Comments:
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