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Forms Manager
Health Promotion OUTREACH Form
DATE of OUTREACH
MM/DD/YYYY
TITLE of OUTREACH
DESCRIPTION of OUTREACH
TARGET AUDIENCE
All Students
CSB Students
SJU Students
First-year (CSB & SJU Students)
Sophomore (CSB & SJU Students)
Junior (CSB & SJU Students)
Senior (CSB & SJU Students)
First-year (CSB students)
Sophomore (CSB students)
Junior (CSB students)
Senior (CSB students)
First-year (SJU students)
Sophomore (SJU students)
Junior (SJU students)
Senior (SJU students)
Classroom
Faculty/Staff
Prospective Students
Residential Life Student Staff
Health Promotion Team Members
TYPE of OUTREACH
Media Campaign
Educational Information
Resources
Interactive Activity
Interactive Discussion
Public Relations
Training
Other
METHOD of OUTREACH (Check all that apply)
General E-mail
Facebook
Instagram
Snapchat
Twitter
Presentation
Training Session
Resource Fair
Newspaper/Poster
Other
PLANNING HOURS
round hours to the nearest half hour and enter as .50 (not .30)
IMPLEMENTING HOURS
round hours to the nearest half hour and enter as .50 (not .30)
NUMBER of STUDENTS/FACULTY/STAFF/COMMUNITY RESIDENTS REACHED
PEER GROUP/DEPARTMENT
stop@buzzed
Dream Team
HA – Health Advocates
SJHI – Health Initiative
CERTS
Health Promotion
Counseling
FORM COMPLETED BY
First and Last Name
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