* Required Name: *
Phone: *
E-mail: *
Department Name:
Department Head:
Name of Event:
Type of Event: Screening Educational
Location of Event:
Language of Event:
Number of Attendees:
Who was the targeted population?
What were the goals and objectives of the event?
If the event is classified as a screening event, how many attendees reported positive?
How many referrals, if any, were generated?
What follow up was provided? Select all that apply? Further Testing Resources Provided Appointments scheduled Results of screenings communicated to patients Other How many referrals, if any, were generated?
Were any service gaps identified? (e.g. insurance issues, language barriers, lack of access, etc.)
What, if any, other community organizations participated? (e.g. American Cancer Society, Cancer Care, Medicaid, etc.)
How was the event advertised? (check all that apply) Referrals Newspapers Mail Flyers Internet/Web-based Other
Were the goals and objectives of the event met? Yes No Partly Cannot be Determine Comments Additional Comments:
