Kaity's Way Post Event Data Gathering

Thank you for filling out this form. The information you are about to provide helps Kaity's Way in so many ways. We are able to determine our costs as well as show potential donors how active we are in the community and that the population we serve is very diverse on so many levels.

Event Date and Start time *

MM

/

DD

/

YYYY

Time

:

Event/Venue Name *

Your answer

Event Location Street Address *

Your answer

Event City, State, Zip *

Your answer

Name of person completing this form *

Your answer

Names of any volunteers that helped with the event *

if no one else helped just indicate none

Your answer

Facilitators Time of Arrival to the Event *

Facilitator is the lead person for the event. This time is usually earlier than the time of the event to allow for set up

Time

:

Time of Departure from the Event *

Time

:

Time spent setting up and breaking down *

This time frame should include requests to stay behind for additional Q&A or required early arrival

Hrs

:

Min

:

Sec

Actual time spent Presenting *

Hrs

:

Min

:

Sec

Travel Time *

Round trip

Hrs

:

Min

:

Sec

Air, Bus, Train transportation cost *

If applicable, indicate total cost for ticket(s)... if not, put 0

Your answer

Mileage *

How many miles were traveled to get to and from the event

Your answer

Car rental fee *

If so, indicate amount of rental fee. If not, indicate 0 (number zero)

Your answer

Gas for trip *

If so, indicate amount below. If not, indicate 0 (number zero)

Your answer

Lodging cost *

If so, indicate amount below. If not, indicate 0 (number zero)

Your answer

Per Diem *

If so, indicate amount below. If not, indicate 0 (number zero)

Your answer

This data is gathered for reporting and grant writing purposes

Please follow directions carefully

Indicate the number of people in the audience that appeared to be of the following ethnicities.

Put 0 (number zero) if there were none

Put 0 (number zero) if there were none

Caucasion *

Indicate number of people in audience that appeared Caucasion

Your answer

Native American *

Indicate number of people in audience that appeared Native American

Your answer

Hispanic *

Indicate number of people in audience that appeared Hispanic

Your answer

African American *

Indicate number of people in audience that appeared African American

Your answer

Asian *

Indicate number of people in audience that appeared Asian

Your answer

Middle Eastern *

Indicate number of people in audience that appeared Middle Eastern

Your answer

Other *

Indicate number of people in audience that appeared to be other than the above mentioned ethinicities

Your answer

Male *

Indicate number of males in the audience

Your answer

Female *

Indicate number of females in the audience

Your answer

12 yrs - 15 yrs *

Indicate number of audience members that appeared to be in this age range. 0 (number zero) for None

Your answer

16 yrs - 18 yrs *

Indicate number of audience members that appeared to be in this age range. 0 (number zero) for None

Your answer

19 yrs - 24 yrs *

Indicate number of audience members that appeared to be in this age range. 0 (number zero) for None

Your answer

25 yrs and older *

Indicate number of audience members that appeared to be in this age range. 0 (number zero) for None

Your answer

This area is the keep track of the cost of materials provided to the community.

Please indicate number of each item given out at the event.

0 (number zero for None)

Kaity's Way Brochure - English *

Your answer

Kaity's Way Brochure - Spanish *

Your answer

P.E.A.C.E./KL Sp 2 sided *

Your answer

Teen Power & Control Wheel (Eng/Sp) 2 sided *

Your answer

LGBTQ Power & Control Wheel (Eng/Sp) 2 sided *

Your answer

CDC TDV Information 2 sided *

Your answer

Bracelets *

Your answer

Prizes *

Your answer

Admin Paperwork *

Event set up form, sign in sheets, etc

Your answer

Pre Survey 1 side

Your answer

Post Survey 2 side

Your answer

Was an Honorarium provided?

If so, indicate amount below

Your answer

What type of Event was this *

Presentation

Workshop

Program Presentation

Train the Trainer

Presentation/Resource Table

Workshop/Resource Table

Resource Table

Keynote Speak

Keynote Speak/Resource Table

Panel

Debriefing

Appearance

Other:

Comments

Your answer

Number in Attendance *

Estimate the number of people that attended the event

Your answer

Number of people served *

This number for a presentation will be the same as number in attendance. For a resource table record the number of people that stopped by the table.

Your answer