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Community Outreach Reporting Tool
The following information should be reported by the events Lead Facilitator. Please contact Madison MacLean (madison_maclean@jsi.com) with questions.
1.
If your event was for a specific County, please choose it from the drop-down menu. If not, please skip to Question 2.
Androscoggin
Aroostook
Cumberland
Franklin
Hancock
Kennebec
Knox
Lincoln
Oxford
Penobscot
Piscataquis
Sagadahoc
Somerset
Waldo
Washington
York
2.
If your event was for a specific community, please select it from the drop-down menu.
Veterans
Adult 65+ with chronic conditions
Youth
People experiencing homelessness
LGBTQ+
Rural residents
People experiencing mental health challenges
People experiencing a substance use disorder or are in recovery
People who are deaf or experiencing hearing loss
People with a physical disability
People living with HIV/AIDS
3.
Name of event
4.
Date of event
5.
If the event was held in person, report the name and location of the venue.
6.
Number of participants
7.
Lead facilitators' name(s)
8.
Lead facilitators' email(s)
9.
List the organizations represented at this event
10.
List the indicators identified as concerning by your participants, and the number of times those indicators were mentioned (e.g., e-cigarette use by middle school students – 3 votes; days missed due to poor health – 4 votes).
11.
List the top four Health Priority Topic Areas identified at this event, along with the total number of votes, in ranked order.