3 CHA Diary

O.M.B 0925-0491

Exp. XX/XX

JACKSON HEART STUDY COMMUNITY HEALTH ADVISOR’S DIARY (REVISION # 3)

DIRECTIONS – Please write the number of times you did each activity this month. If you did something that is not listed write it on the back of this page. Please mail or fax to the Community Partnership Office the last day of each month. Thank you.

Public reporting burden for this collection of information is estimated to average 6-15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0491). Do not return the completed form to this address.

	PARTICIPATION ACTIVITIES		COORDINATION ACTIVITIES		CONDUCTION ACTIVITIES
	Attended a health fair		Presented at a church health fair		Implemented a CHAN sustainability activity in my community
	Attended a benefits fair at work		Presented at a sorority meeting		Conducted a CHAN sustainability meeting in my community
	Shared stroke symptoms information w/ others at beauty shop		Church service announcement about the Jackson Heart Study		Wrote a health improvement article/editorial to the local newspaper
	Shared heart attack symptoms w/ others at barber shop		Displayed heart disease and Jackson Heart Study information at a health fair		Spoke at a school during American Heart Month or anytime
	Encouraged someone to see their physician		Presented at the statewide CHA conference		Held a press conference for National Stroke Awareness Month
	Attended a CHAN sustainability meeting in my community		Presented at the national CHA conference		Wrote a mini-grant to purchase health related items for community use
	Attended the national CHA Conference		Joined a committee in my CHAN sustainability group		Organized a statewide advisory committee for Mississippi CHAs

Name _________________________________________________________________ Date ________________________________

	PARTICIPATION ACTIVITIES		COORDINATION ACTIVITIES		CONDUCTION ACTIVITIES
	OTHER		OTHER		OTHER

Form Corrections _____________________________________________________________________________________________

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Mailing Address: Community Partnership Office FAX NUMBER: 601-979-8701

350 Woodrow Wilson Avenue, Suite 701

Jackson, Mississippi 39213