Use this form to summarize the elements of outreach activities

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Title of the activity in this report

Name of the outreach personnel submitting this evaluation and other personnel

Date of the activity


Time associated with the activity; preparation, travel, conducting, and evaluating

List the objectives of the activity

Indicate if you think the objectives were met, and make a comment if needed

List the items that went well

Indicate any issues or problem encountered

List any changes made, how problems were solved, or adaptations created

List any suggestions for future events

List the titles of: prepost tests, surveys, or informal assessment tools

List any other comment

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