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1. KFAP Activity Reports

Get credit for the activities you do!
Complete your activity report below.
Be sure to click "DONE" when you are finished.
Thanks for all you do!

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* 1. Name

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* 2. Agency/Organization (Please select from list or choose "Other" and use second line to type in your information.)

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* 3. Kentucky County of Activity (Please select from list or choose "Other" and use second line to type in a county in another state.)

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* 4. City or town (optional)

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* 5. State

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* 6. Email address

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* 7. If you are a health department employee in Kentucky: Has this activity been reported in the health department's Community Health Services system?

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* 8. What was the topic of the activity?

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* 9. Please enter the date the activity was completed.

Date

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* 10. What was the site of the activity?

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* 11. What type of activity did you do?

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* 12. How many people did your activity reach? (Enter numbers only)

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* 13. Description/comments: Please give a detailed description that will appear in the monthly report exactly the way you enter it.

Information to include:
* WHO did the activity
* WHAT was done
* HOW it was done
* TARGET AUDIENCE (include number of women of childbearing age)
* MATERIALS distributed (type and quantity)
* Source of FUNDING or any IN-KIND contributions
* Any other details of interest

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* 14. If you have any images or other files to document the activity, please attach them here. Only PDF, DOC, DOCX, PNG, JPG, JPEG, GIF files are supported.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
Choose File

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