Arthritis Program Logging

System Information

Logging Type:

Logging Item:

Create Date:

Health Department

Kentucky Department for Public Health

Kentucky Chronic Disease Prevention Branch- Arthritis Program

Local Health Department Reporting Form

Education- Outreach- Awareness

Year Reporting Period Occured:

Reporting Period:

Health Department:

Staff Contact:

Phone:

Email:

Attention Field Staff: You may report up to 5 activities on each report. Please complete an additional report if needed. Thank you, KOAP Staff

Arthritis Intervention Report

Do you have any program interventions to report this quarter? YesNo*

Arthritis Interventions

Site of Program/School:

Target Audience:

Additional Information:

Name of Instructor (Last):

Name of Instructor (First):

Reach (# of Participants):

Reach (New Only)

Arthritis Intervention

Site of Program/School:

Target Audience:

Additional Information:

Name of Instructor (Last):

Name of Instructor (First):

Reach (# of Participants):

Reach (New Only)

Arthritis Intervention

Site of Program/School:

Target Audience:

Additional Information:

Name of Instructor (Last):

Name of Instructor (First):

Reach (# of Participants):

Reach (New Only)

Arthritis Intervention

Site of Program/School:

Target Audience:

Additional Information:

Name of Instructor (Last):

Name of Instructor (First):

Reach (# of Participants):

Reach (New Only)

Arthritis Intervention

Site of Program/School:

Target Audience:

Additional Information:

Name of Instructor (Last):

Name of Instructor (First):

Reach (# of Participants):

Reach (New Only)

Education and Awareness

Did you provide any other type of arthritis education or awareness? YesNo*

If yes, please describe.

Media Campaign

Any new publications during the reporting period? (articles, newspaper, website, flyer, etc.) YesNo*

Short description of media:

Please email a copy of the media publication to Kentucky.Arthritis@ky.gov.

New Delivery Partners

Any new delivery partner(s) recruited this quarter?

YesNo

If yes, please describe the partner and their role

Outreach/Referral - Health Care Provider

Were you able to contact a local health care provider?

YesNo

If yes, did the HCP agree to assist the program?

YesNo

If yes, what is the HCP role?

Program Materials (Delivery)

Any arthritis program materials delivered during this reporting period? YesNo*

Total Number Delivered

Walk With Ease Brochure

CDC Physical Activity Brochure

CDC Arthritis Bookmark

Walk With Ease Tear Away Pad

Walk With Ease Book

If Other:

Program Materials (Request)

Total Number Requested

Are you requesting additional Arthritis program materials? YesNo*

Walk With Ease Brochure

CDC Physical Activity Brochure

CDC Arthritis Bookmark

Walk With Ease Tear Away Pad

Walk With Ease Books

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