Online Activity Report
 

Get credit for the activities you do!  Complete your activity report below. 
Be sure to click the SUBMIT button when you are finished.  
Thanks for all you do!
  1. Has this activity been reported in the Health Department Community Health Services system?
Answer "No" unless you completed a CHS report with the objective/program code of either 1212- or 1216-
  1. Topic of activity*

 

If the topic is not listed, select "Other" from the list above and enter it here:

  1. Member agency/organization*
  
If your agency/organization is not listed,
select "Other" from the list above
and enter it here:
  1. Activity date*
 IMPORTANT!  Enter as mm/dd/yyyy
 
  1. Entered by:
 Please type in your name
  1. Committee

  1. Location of activity*
     
 Counties are listed alphabetically.
States are at the bottom of the drop-down list.  
 
If the location is not listed, select "Other" from the list above
and enter it here: 
  1. Activity site

  1. Activity type*

 
  1. Target audience*

 
  1. Number of people reached
  
  1. Number of women of childbearing age reached
  
  1. Number of materials distributed
  
  1. Cost or in-kind value
 $
  1. Source(s) of funding or in-kind
  

  1. Description/comments*

Please give a detailed description that will appear in the monthly report exactly the way you enter it.  Include:

bullet

Who did the activity

bullet

What was done

bullet

How was it done

bullet

Any other details of interest

  
Complete lines 16-22 for media activities only. 
If this is not a media activity, skip to the bottom and click the Submit button to complete your report.
  1. Media type.  Check one--please submit a separate activity report for each type of media.

If the media type is not listed, select "Other" from the list above
and enter it here: 

  1. Purpose (choose one main purpose)

If the purpose is not listed, select "Other" from the list above,
and enter it here:

  1. Media format


If the format is not listed, select "Other" from the list above,
and enter it here:

  1. Name of media outlet
  
  1. Number of placements
  
  1. Number of follow-up calls
  
  1. Number of times aired
  
*Required