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

METHOD of OUTREACH (Check all that apply)

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

FORM COMPLETED BY

First and Last Name

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