LHG Website: Submit a Story Survey

We are always looking for ways to feature communities across Georgia who are working on great initiatives to increase policies, systems and environmental changes at the local level. If this is you, please complete the following survey and you may be featured on our website!

1. What county or counties are you working in?

What county or counties are you working in?

2. Please fill in your contact information below:

Please fill in your contact information below: Full Name:
Organization:
Address:
Address 2:
City/Town:
State:
ZIP:
Country:
Email Address:
Phone Number:

3. What community sector does your success story represent?

What community sector does your success story represent? Community Institution/Organization Sector includes entities within the community that provide a broad range of human services and access to facilities, such as childcare settings, faith-based organizations, senior centers, boys and girls clubs, YMCAs, and colleges or universities.

Health Care Sector includes places where people go to receive preventive care or treatment, or emergency health care services, such as hospitals, private doctors' offices, and community clinics.

School Sector includes all primary and secondary learning institutions (e.g., elementary, middle, and high schools, whether private, public, or parochial).

Work Site Sector includes places of employment, such as private offices, restaurants, retail establishments, and government offices.

Community-At-Large Sector includes communitywide efforts that impact the social and built environments, such as improving food access, walkability or bikeability, tobacco use and exposure, or personal safety.

4. What types of changes are you working on? (Please check all that apply)

What types of changes are you working on? (Please check all that apply) nutrition policies to affect a system (e.g. school system)

nutrition policies to affect the environment (e.g. farmers market/community garden etc.)

physical activity policies to affect a system (e.g. school system)

physical activity policies to affect the environment (e.g. safe routes to schools, safe park etc.)

tobacco policies to affect a system (e.g. school system)

tobacco policies to affect an environment (e.g. tobacco free ordinance etc.)

chronic disease intervention (CDSMP success, Heart Disease and Stroke success, healthcare system-community linkage, etc.)

healthcare (clinical) practice policies (e.g. hospital system adoption of guidelines for patient care)

social marketing awareness initiative (media campaign, grassroots awareness(signs & symptoms) etc.)

Other (please specify)

5. SUCCESS STORY TITLE:

SUCCESS STORY TITLE:

SELF-CHECK - HAVE YOU?

□ Captured the overall message of the story?
□ Included an action verb?
□ Captured the reader’s attention?

6. PROBLEM OVERVIEW:

PROBLEM OVERVIEW:

SELF-CHECK - HAVE YOU?

□ Described the problem being addressed and why it’s important?
□ Used data to frame the problem, including health burden and economic costs?
□ Specified the affected population(s)?

7. PROGRAM/ACTIVITY DESCRIPTION:

PROGRAM/ACTIVITY DESCRIPTION:

SELF-CHECK - HAVE YOU?

□ Identified who was involved, including your partners?
□ Described the program/activity that was implemented, including where and when it took place and how it addressed the problem?
□ Identified the target audience of the program/activity?
□ Described how the progress of the program/activity is evaluated?
□ Stated how DPH support (if applicable) contributed to the program/activity?

8. PROGRAM OUTCOMES:

PROGRAM OUTCOMES:

SELF-CHECK HAVE YOU?

□ Identified the short-term or intermediate outcomes that demonstrate how the program/activity addressed the problem (e.g., change in policy, use of curriculum, change in school-level practices, establishment of additional funding, etc.)?
□ Briefly described your FIVE most significant accomplishments of the program/project.
□ Provided a conclusion to the success story that avoids using broad, sweeping statements such as “There was a noticeable increase in healthy eating habits”?

9. STORY ABSTRACT:

STORY ABSTRACT:

SELF-CHECK HAVE YOU?

□ Summarized the problem, program/activity, and outcomes?
□ Described what you consider the most important success of your program to
date.

10. Place share any other supporting information for your success story below and
submit any material (photos etc.) via email to livehealthygeorgia@dhr.state.ga.us
with the title of your success story in the subject line.

Place share any other supporting information for your success story below and submit any material (photos etc.) via email to livehealthygeorgia@dhr.state.ga.us with the title of your success story in the subject line.

11. If any of the following are being submitted to complement your story, please check all that apply:

If any of the following are being submitted to complement your story, please check all that apply: Testimonials

Quote from Partner/Participant

Sample of Materials Produced

Press Release

Promotional Materials

Photo(s) of Project

Video/Audio Clip

Other (please specify)

12. DOES DPH HAVE PERMISSION TO SHARE THIS SUCCESS STORY?

DOES DPH HAVE PERMISSION TO SHARE THIS SUCCESS STORY? Yes

Thank you for taking the time to share your community success story with us! Please keep checking back at http://www.livehealthygeorgia.org/stories.shtml!

LHG Website: Submit a Story

Community Success Story Submission