Instructions for Event Summary

Program Information
1. Event Name: Program title (matching HU, if applicable), i.e.: Wellness Screenings, Healthy Hearts, Parkinson’s Support Group. This is not the program location.

2. Location: ie: Jackson Senior Center, Clifton Health Department, HUMC. This is not Conference Room A, Basement Meeting Room, etc.

3. City, State and Zip Code: Entire street address is not necessary.

4. Date: Month, Day, Year; example 7/12/2022

5. Start Time: of event, not staff hours, ie: 9:30 a.m.
     End Time: of event, not staff hours, ie: 11:30 a.m.

6. Venue Type: Select option that best describes the location of the event.

7. Campus: Selection should reflect market area where program took place.

8. 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
1. Attendees: Number of people who attended the event.

2. Consents: Number of people who were screened at the event, if applicable.

3. Population Served: Consider the majority of the people and select one or more from the options listed.

4. Race: Consider the majority of the people in attendance and select one or more from the options listed.

Speakers, Services & Referrals
1. Speaker Name and Credentials: First name last name and primary credentials; ie: DO, MD, RN, PT. Select credential options provided. List up to five speakers per event.

2. 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

3. Referrals: Indicate the number of referrals and where referred to if you need to track this information.

4. Grant: Check box if the event is sponsored or partially sponsored by a grant.

5. 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.