Community Health Impact Research Evaluation
Help us assess the effectiveness and outcomes of our community health program by completing this evaluation form.
Project or Program Name
*
Your Role in the Project
*
Please Select
Participant
Volunteer
Community Leader
Healthcare Provider
Project Coordinator
Other
Full Name
*
First Name
Last Name
Email Address (for follow-up, optional)
example@example.com
Age Group
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 or older
How would you rate the overall impact of the program on community health?
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1
2
3
4
5
Which health areas have shown improvement due to the program? (Select all that apply)
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Physical Activity
Nutrition
Mental Health
Chronic Disease Management
Access to Healthcare
Health Awareness/Education
Other
Describe any specific changes or improvements observed in the community as a result of the program.
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What challenges or barriers did you encounter during the program?
Suggestions for improving the program or future initiatives
Do you consent to have your responses used for research and program improvement purposes?
*
Yes, I consent.
No, I do not consent.
Submit Evaluation
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