HDA Outreach Event Report
Please complete the form below and forward photos of your event to hdaoutreach@gmail.com
Chapter Name: *
Outreach Contact Person *
Telephone Number *
Email Address *
Name of Event *
Event Date *
MM
/
DD
/
YYYY
Brief Description of Event
Event Duration *
Total Number of HDA/HSDA Volunteers *
Total Number of Individuals Served *
Event Type *
Individuals served at this event included: (check all that apply) *
Required
Age 0 - 2 (Number) *
Age 2 - 5 (Number) *
Age 5-11(Number) *
Age 11-18(Number) *
Age 18 - 65 (Number) *
Age 65+ (Number) *
*
N/A
0-2
2-5
5-11
11-18
18-65
65+
Education
Screenings
Sealants
Fluoride
Other Treatment
Describe Treatment if "Other"
Estimated cost of donated services (example: OHI kits valued at $3 each and 100 distributed = $300 total service value) *
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