Maine Shared CHNA Community Outreach Reporting Tool

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* 1. Facilitators’ name(s)

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* 2. Facilitator contact info (in case of questions)

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* 3. Date

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* 4. Venue

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* 5. City

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* 6. County

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* 7. Number of participants

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* 8. Was this event open to the community at large?

Yes

No

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* 9. If no, please describe the participating group.