Coalition members:

Please complete one survey for each relevant activity.

At the end of the survey click the "Done" button to submit your survey report. The survey will automatically refresh to a blank survey so that you may complete another survey as needed.

If you are only submitting one activity survey report you can close out of the tab once you have clicked "Done".

Please email me if you have any questions @ mkabramo@buffalo.edu

Thank you for your time.

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* 1. First Name

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* 2. Last Name

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* 3. What grant funding is this activity supportive of?

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* 4. Number of other Coalition members involved

0 Other Members 5 10 Other Members
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 5. How many hours of planning time did coalition members spend on this activity?

0 hours 10 20 hours
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 6. Name of Organization sponsoring or leading activity

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* 7. Zip Code of activity location or target area

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* 8. Contributing Organization Sectors

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* 9. Title or Short Description of Activity

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* 10. Start Date of Activity

Date

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* 11. End date of Activity

Date

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* 12. Duration of Activity (Total Hours)

0 hours 50 100+ hours
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 13. Total number of instances that activity occurred

0 instances 5 10+ instances
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 14. Targeted Substances

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* 15. Number of adults reached (18 years and over)

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* 16. Number of adolescents reached (Under 18 years old)

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* 17. Opinion - Success of Activity

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* 18. Success Comments

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* 19. Primary Specific Activity Category

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* 20. Additional Specific Activity Category (select up to 3)

T