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Materials Dissemination Log

INSTRUCTIONS: Core Partners — Please complete the following information for each person to whom you've disseminated the 2010 Guide Improving the Health of Adolescents and Young Adults: A Guide for States and Communities and/or other National Initiative materials. Once you've submitted the form, you will get a successful message and an option to fill out a new form.

Recipient Information
1.)  Recipient's Organization: 
2.)  Name: 
3.)  Title:  
4.)  Email:  
5.)  Phone:  
7.)  Address:  
8.)  City, State:   ,  
9.)  Website:  

Type of Organization
  Funder
  Healthcare Provider
  Education
  Health Educator
  Youth Services Org
  Public Health Group
  Contractor
  Community Coalition
  Coordinator Grantee
  Other  
  
Distribution of Materials

If you haven't sent hard-copy materials to recipients, how have you disseminated the 2010 Guide/Other National Initiative materials?

  
Materials Sent
  Number Sent
Executive Summary
Full Document
Individual Chapters  
          Chapter One
          Chapter Two
          Chapter Three
          Chapter Four
          Chapter Five
          Chapter Six
          Chapter Seven
          Chapter Eight
          Closing
          References
Powerpoint Presentation
Newsletter Article
Ordering Instructions
Other
Other
 
  
 
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