Community Success Story Submission

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We are always looking for ways to feature communities across Georgia who are working on great initiatives to increase policies, systems and environmental changes at the local level. If this is you, please complete the following survey and you may be featured on our website!

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1. What county or counties are you working in?

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2. Please fill in your contact information below:

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3. What community sector does your success story represent?

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4. What types of changes are you working on? (Please check all that apply)

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5. SUCCESS STORY TITLE:


SELF-CHECK - HAVE YOU?

□ Captured the overall message of the story?
□ Included an action verb?
□ Captured the reader’s attention?

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6. PROBLEM OVERVIEW:


SELF-CHECK - HAVE YOU?

□ Described the problem being addressed and why it’s important?
□ Used data to frame the problem, including health burden and economic costs?
□ Specified the affected population(s)?

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7. PROGRAM/ACTIVITY DESCRIPTION:


SELF-CHECK - HAVE YOU?

□ Identified who was involved, including your partners?
□ Described the program/activity that was implemented, including where and when it took place and how it addressed the problem?
□ Identified the target audience of the program/activity?
□ Described how the progress of the program/activity is evaluated?
□ Stated how DPH support (if applicable) contributed to the program/activity?

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8. PROGRAM OUTCOMES:


SELF-CHECK HAVE YOU?

□ Identified the short-term or intermediate outcomes that demonstrate how the program/activity addressed the problem (e.g., change in policy, use of curriculum, change in school-level practices, establishment of additional funding, etc.)?
□ Briefly described your FIVE most significant accomplishments of the program/project.
□ Provided a conclusion to the success story that avoids using broad, sweeping statements such as “There was a noticeable increase in healthy eating habits”?

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9. STORY ABSTRACT:


SELF-CHECK HAVE YOU?

□ Summarized the problem, program/activity, and outcomes?
□ Described what you consider the most important success of your program to
date.

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10. Place share any other supporting information for your success story below and
submit any material (photos etc.) via email to livehealthygeorgia@dhr.state.ga.us
with the title of your success story in the subject line.

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11. If any of the following are being submitted to complement your story, please check all that apply:

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12. DOES DPH HAVE PERMISSION TO SHARE THIS SUCCESS STORY?

Thank you for taking the time to share your community success story with us! Please keep checking back at http://www.livehealthygeorgia.org/stories.shtml!

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