School Health Outreach Report Form

School Health Outreach Report Form
Document all key details of your school health outreach activity for program monitoring and follow-up.
Outreach Event Title
Date of Outreach Activity
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
School Name
School Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Location Type
Organizing Team/Organization
Health Topics Covered
Other
Number of Participants Reached
Services Provided
Other
Observed Health Concerns
Other
Referrals Made
Other
Follow-up Needs Identified
Other
Materials Distributed
Other
Overall Outcome and Notes
Should be Empty:

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