CLDit Lock Box Data Collection Form
Please provide some information about the patient/customer/client who received a personal lock box to protect the members of their household. (One form/zip code, please. Within a zip code, you can enter as many boxes as were given.)
Total Number of boxes distributed *
Your answer
How many of the participants were male?
Your best guess
Your answer
How many of the participants were female?
Your best guess
Your answer
I don't know the gender of participants
Your best guess of any participant whose gender cannot be verified
Your answer
Ages of Participants
How many participants were from each of the following age groups?
0 - 4
Your answer
5 - 11
Your answer
12 - 14
Your answer
15 - 17
Your answer
18 - 20
Your answer
21 - 24
Your answer
25 - 44
Your answer
45 - 64
Your answer
65 and over
Your answer
Number of participants whose age you don't know
Ideally all of these numbers will add up to the total participation
Your answer
Race
Number of participants from each race listed below.
White
Your answer
Black/African American
Your answer
Native Hawaiian / Other Pacific Islander
Your answer
Asian
Your answer
American Indian / Alaskan Native
Your answer
More than one race
Your answer
Race Unknown or Other
Your answer
Ethnicity
Were participants Hispanic or Latino?
Hispanic or Latino
Your answer
Not Hispanic or Latino
Your answer
Unknown
Your answer
Zip Code where box will be used.
Your answer
Thank you for taking the time to help us record data about this initiative.
And thanks for helping to promote our Count It, Lock It, Drop It campaign. Please feel free to contact the Coalition if we can provide any more help or support.
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