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: