Leadership Council for Healthy Communities
HEALTH COORDINATOR MONTHLY REPORT
Name of Site *
Your answer
Report Month and Year *
Your answer
Ward *
Type of Activity, date(s) and number attendees *
List type of activity, date and number of attendees
Your answer
Number of Attendees
Total number of attendees for the month
Your answer
Health Information Disseminated *
Topic and how many distributed?
Your answer
Health Information Disseminated
Topic and how many distributed?
Your answer
Health Screenings
How many Health screenings?
Your answer
Discussion topic and presenter, if any
Name, title, organization and presentation topic
Your answer
Describe how the activity/event increased access to and/or awareness of community prevention health services that help manage chronic diseases especially diabetes, cardiovascular disease, stroke, and/or hypertension. *
Your answer
Type of Referral (all activities) *
(choose all that apply)
Yes
No
Chronic Disease Service Provider
Faith Institution Event/Workshop
Health Prevention Information
Physical Activity
Medical Home
Nutrition Training/Workshop
Community or Social Service
Transportation
Resources Used for Referral (all activities) *
(choose all that apply)
Yes
No
Aging and Disability Resources
ChronicDiseaseLocal
DC Department of Parks and Recreation Facility Locator
DC Health Link - Doctor Directory
Healthify
LCHC Website
LCHC Ward Directory
Other
Did the referral resources provided meet the particpant's need? *
Rate your experience working with the resources provided for direct service to participants. *
Satisfied
Not Satisfied
Did Not Use
Aging and Disability Resources
Chronic Disease Local
DC Department of Parks and Recreation Facility Locator
DC Health Link - Doctor Directory
Healthify
LCHC Website
LCHC Ward Directory
Other
Successes/Challenges
Your answer
Your comment and feedback concerning the technology or resource mangement tools for the program.
Your answer
Next Activity
Health Fair
Workshop
Multi-disciplinary partner activity
Training Session
Type of Next Activity
Date of Next Activity *
MM
/
DD
/
YYYY
Signature of Authorized Representative *
Your answer
Contact Number
Your answer
Date *
Date form completed
MM
/
DD
/
YYYY
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