Community Outreach Event Summary

Instructions for Event Summary

Program Information

  • Event Name: Program title (matching HealthViews, if applicable), ie: Wellness Screenings, Healthy Hearts, Parkinson’s Support Group. This is not the program location.
  • Location: ie: Jackson Senior Center, Clifton Health Department, HUMC. This is not Conference Room A, Basement Meeting Room, etc.
  • City, State and Zip Code: Entire street address is not necessary.
  • Date: Month, Day, Year; example 7/12/2019
  • Start Time: of event, not staff hours, ie: 9:30 a.m.
  • End Time: of event, not staff hours, ie: 11:30 a.m.
  • Venue Type: Select option that best describes the location of the event.
  • Campus: Selection should reflect market area where program took place.
  • Event Type: Choose the appropriate category or categories for the event. Appearance is for Pawsitive Action Team programs only. A special event is defined as program that is unique or a one off (although you can do it more than once but not on a regular basis: i.e. walks/runs, special cooking events, dance a thon, etc. This can also be an event you participate in not one solely run by Hackensack Meridian Health.)

Attendance Information

  • Attendees: Number of people who attended the event.
  • Consents: Number of people who were screened at the event, if applicable.
  • Population Served: Consider the majority of the people and select one or more from the options listed.
  • Race: Consider the majority of the people in attendance and select one or more from the options listed.
  • a. American Indian or Alaskan Native
  • b. Asian: Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Other Asian
  • c. Black or African American
  • d. Hispanic or Latino
  • e. Native Hawaiian or other Pacific Islander
  • f. White

Speakers, Services & Referrals

  • Speaker Name and Credentials: First name last name and primary credentials; ie: D.O., M.D., RN, PT. Select credential options provided. List up to five speakers per event.
  • Care Transformation Services: Select the appropriate service(s) for program topic and screenings offered from those listed. Also, use this to indicate if a hospital department participated in the event.
  • Referrals: Indicate the number of referrals and where referred to if you need to track this information.
  • Grant: Check box if the event is sponsored or partially sponsored by a grant. Screening Information
  • Indicate the number of each screening provided and the number of abnormal or out of range screening results, ie: If the team provided 55 blood pressure screenings and 8 were abnormal, you would indicate as follows: Blood Pressure 55/8

At the bottom of the form, please fill in the name of person who completed the form and the date. Click the submit button at the end of the online form or email the PDF version of the form to

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