Form 0920-1161 Partnership Activities Form

Evaluation of Enhancing HIV Prevention Communication and Mobilization Efforts through Strategic Partnerships

Att 3f Partnership Activities Form

Att. 3f_Partnership Activities Form

OMB: 0920-1161

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Form Approved

OMB No: 0920-New

Exp. Date: XX/XX/XXXX







Evaluation of Enhancing HIV Prevention Communication and

Mobilization Efforts through Strategic Partnerships




Attachment 3f

Partnership Activities Form













Public reporting burden of this collection of information is estimated to average 25 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)



Partnership Activities Form

Organization: Organization Name

Begin date: Click here to enter a date.

End date: Click here to enter a date.

Partnership type:

If an unfunded partner, is your organization affiliated with the Business Response to AIDS (BRTA) initiative?

If a funded partner, are you a part of Partnering and Communicating Together to Prevent HIV (PACT)?

Point of contact: Name

Email: Email Address

Phone: Please include area code.

EVENT

Event: Name of Event

Event location: (If applicable) City, State, Zipcode

Approximate attendance: How many people were there?

Event type:

Description:

Please provide a description of the event. Please describe the audience and key highlights .

Were HIV tests administered?

Number of HIV tests administered: Click here to enter text.

Number of preliminary positives: Click here to enter text.

Did other partners (internal or external), chapters or affiliates of your organization, or sponsors have a role or help in this activity? If yes, list all involved:

Materials Distributed

Were any materials distributed?

If yes, please select campaign, materials type and enter quantities below:


Campaign: Materials Type: Quantity: Click here to enter text.

Campaign: Materials Type: Quantity: Click here to enter text.

Campaign: Materials Type: Quantity: Click here to enter text.

Campaign: Materials Type: Quantity: Click here to enter text.

Campaign: Materials Type: Quantity: Click here to enter text.

Campaign: Materials Type: Quantity: Click here to enter text.

Campaign: Materials Type: Quantity: Click here to enter text.


Other Materials:

Please describe any other materials used and the corresponding quantities.

Please select distribution channel(s) (check all that apply):

☐ Funded Partner Unfunded Partner Participant Network CDC and CDC-INFO Bulk Order

☐ Event Conference Gay Pride Event CDC Contractor Internet

Receiving organization name: Click here to enter text.

Receiving organizations type:

If there are more than one receiving organization types, please list here: Click here to enter text.

INTERNET AND SOCIAL MEDIA

Internet:

Did this event involve Internet ads?

Website URL: Click here to enter text.


Number of Internet Ads Placed: Click here to enter text.

Internet Ad Impressions: Click here to enter text.

Clicks from Online Advertisements Click here to enter text.

Social Media:

Did this event involve social media?

If yes, please check all social media platforms used:

☐ Blogs

☐ Twitter

☐ Facebook

☐ YouTube

☐ Flickr

☐ Instagram

☐ Other

If other, explain: Please provide as much detail as possible.

Facebook


Page Name:

Date: Click here to enter a date.

Post: Click here to enter text.

Likes: Click here to enter text.

Shares: Click here to enter text.

Comments: Click here to enter text.

Twitter


Account Name:

Date: Click here to enter a date.

Number of Tweets: Click here to enter text.

Number of Tweets on hashtag (#): Click here to enter text.

Blog or Other Social Media


Page Name:

Date: Click here to enter a date.

Post: Click here to enter text.

Likes: Click here to enter text.

Shares: Click here to enter text.

Comments: Click here to enter text.

MEDIA

Was there media activity?

If there were multiple media activities, please list individually:


Media Activity # 1

Begin date: Click here to enter a date.

End date: Click here to enter a date.

What type of media?

Please select all media outlets that apply:

☐ Internet

☐ TV

☐ Print

☐ Out-of-home

☐ Radio

☐ Other

If other, explain: Click here to enter text.

Media Activity # 2

Begin date: Click here to enter a date.

End date: Click here to enter a date.

What type of media?

Please select all media outlets that apply:

☐ Internet

☐ TV

☐ Print

☐ Out-of-home

☐ Radio

☐ Other

If other, explain: Please provide as much detail as possible.


Media Activity # 3

Begin date: Click here to enter a date.

End date: Click here to enter a date.

What type of media?

Please select all media outlets that apply:

☐ Internet

☐ TV

☐ Print

☐ Out-of-home

☐ Radio

☐ Other

If other, explain: Click here to enter text.

Media Value

Was the media donated?

Was the media paid?

What is the media value? Click here to enter text.

Overall Comments: Click here to enter text.



Please complete form and submit to [CONTACT] by [TIME FRAME]

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorClayton Whitehead
File Modified0000-00-00
File Created2021-03-10

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