SSB Attachment 2 |
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INSTRUCTIONS: Please consider for certainty community nominations those communities that you would characterize as highly active over the past decade (2001 - 2011) in addressing obesity or obesity-related factors (e.g., diet and physical activity) among children and youth. For the purposes of the Healthy Communities Study, a “community” is the geographic equivalent of a public high school catchment area. However, you may nominate communities at different levels of geographic specificity (e.g., city, neighborhood, county). Please provide information about obesity-related programs and/or policies in this community in the appropriate spaces below. |
NOMINATED COMMUNITY |
1a |
Community Name |
<Enter text> |
1b |
How would you characterize this community geographically? |
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Other: |
1c |
Community Location: County |
1d |
Community Location: State/U.S. Territory |
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1e |
Please provide a few sentences about why you believe this community merits inclusion in the HCS |
<Enter text> |
PROGRAM INFORMATION |
INSTRUCTIONS: Please provide the following details about any program(s) addressing obesity or obesity-related factors in the nominated community. If you would like to describe more than 10 programs, please insert additional rows below item "2j". |
2 |
Program Name |
Funding Organization/Sponsor |
Funding Amount |
Duration of Program (including year ended, if applicable) |
Geographic Area Targeted by Program (e.g., Entire Community, Other - if Other, please describe) |
Links/Public Documents with More Information about Program |
2a |
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<Enter a dollar amount> |
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<Enter references> |
2b |
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<Enter a dollar amount> |
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<Enter references> |
2c |
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<Enter a dollar amount> |
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<Enter references> |
2d |
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<Enter a dollar amount> |
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<Enter references> |
2e |
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<Enter a dollar amount> |
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<Enter references> |
2f |
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<Enter a dollar amount> |
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<Enter references> |
2g |
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<Enter a dollar amount> |
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<Enter references> |
2h |
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<Enter a dollar amount> |
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<Enter references> |
2i |
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<Enter a dollar amount> |
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<Enter references> |
2j |
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<Enter a dollar amount> |
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<Enter references> |
POLICY INFORMATION |
INSTRUCTIONS: Please provide the following details about policies addressing obesity or obesity-related factors in the nominated community. If you would like to describe more than 10 policies, please insert additional rows below item "3j". |
3 |
Policy Name |
Implementing Organization |
Duration of Policy (including year ended, if applicable) |
Geographic Area Targeted by Policy (e.g., Entire Community, Other - if Other, please describe) |
Links/Public Documents with More Information about Policy |
3a |
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<Enter references> |
3b |
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<Enter references> |
3c |
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<Enter references> |
3d |
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<Enter references> |
3e |
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<Enter references> |
3f |
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<Enter references> |
3g |
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<Enter references> |
3h |
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<Enter references> |
3i |
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<Enter references> |
3j |
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<Enter references> |
NOMINATOR CONTACT INFORMATION |
4a |
Name: |
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4b |
Organization: |
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4c |
Address: |
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4d |
City: |
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4e |
State: |
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4f |
Phone: |
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4g |
Email: |
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