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PEER Ambassador Check-In Form
Monthly PEER Ambassador Activity Log (can be filled out monthly by PEER Ambassador, by Host Site Supervisor, or by both together)
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Name:
Your answer
Host Site
Choose
Salasin Center
Recover Project (Greenfield)
Community Action Family Center
Valuing Our Children
The Brick House
Reporting on the month of:
Choose
January
February
March
April
May
June
July
August
September
October
November
December
How many hours did you spend in outreach this month? If you are reporting more than 20 hours, please include the number in your comments.
Choose
0
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2
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4
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20
OUTREACH: Did you do any outreach to other parents as a PEER Ambassador in the past month (check all that apply)?
No, I did not reach out to other parents in my role as a PEER Ambassador this month.
Yes, I reached out to other parents by sharing information through social media.
Yes, I reached out to other parents directly through texting, emails, phone calls or other direct communication.
Yes, I reached out to other parents directly through in-person communication.
Yes, I reached out to other parents directly through an in-person outreach event.
OUTREACH: About how many parents did you share information and resources with this month (please enter your best guess as an estimate)?
Your answer
OUTREACH: Did you table at any events this month? If so, please enter the names and dates of events here:
Your answer
OUTREACH: Did you help sign any parents up for evidence-based Parent Education Programs in the community this month? If so, please enter the names and locations of the programs here: (For example - I referred two families to the Strengthening Families program at The Brick House)
Your answer
OUTREACH: Please feel free to share any particular successes or challenges reaching out to peers.
Your answer
INPUT: Did you attend any meetings where you gave input as a PEER Ambassador in the past month?
0
1
2
3
4
PEER Ambassador Meetings
Parent Education Workgroup Meetings
Committee Meetings at my Host Site
Other
0
1
2
3
4
PEER Ambassador Meetings
Parent Education Workgroup Meetings
Committee Meetings at my Host Site
Other
Clear selection
INPUT: If you selected "Other", what other meetings did you attend?
Your answer
LEARNING: How many (if any) trainings, webinars, or workshops about best practices in substance use prevention, youth development, parenting, outreach, etc. did you participate in in the past month?
None this month
1
2
3
4 or more
Clear selection
LEARNING: If you participated in any trainings, webinars or workshops, what were they?
Your answer
LEARNING: If you participated in any trainings, webinars, or workshops did you learn anything particularly useful?
Your answer
Did you get to talk and check in with your Host Site Supervisor this month?
Yes
No
Other:
Clear selection
Did you get to talk and check in with the PEER Ambassador Team Leader (Keyedrya) this month?
Yes
No
Other:
Clear selection
What thoughts do you have for how you would like the next month to go? Are there things you would like to do differently? Are there opportunities you would like to look for?
Your answer
Do you have any thoughts or quotes about the PEER Ambassador Program that you would like to share?
Your answer
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