Partnership for Maternal & Child Health | ELC Report FormPartnership for Maternal & Child Health

NEW ELC FORM 4-1-21

Agency Name*
Agency Target Geography*
Start Date of Reporting Period*
Date Format: MM slash DD slash YYYY
End Date of Reporting Period*
Date Format: MM slash DD slash YYYY
Number of Full-Time Community Health Workers Employed*
Please enter a number from 0 to 15.
Number of Part-Time Community Health Workers Employed*
Please enter a number from 0 to 15.
Number of community members enrolled in the COVID Community Corp Vaccine Registration System Training (include agency staff)*
Please enter a number from 0 to 15.
Describe your target population.*
Describe any development of Technological Tools you have completed during this reporting period.*
Outreach and education – describe any development of health education materials you have completed during this reporting period.*
Describe any new establishment of alternative testing sites during this reporting period.*
Describe any establishment of new contact and/or partnerships between local health departments and your agency*
Outreach Events*
Date (mm/dd/yyyy) Venue/Location (please include municipality) # people present Was Attendance Taken (yes/no) Was NJDOH Strike Team Present (yes/no) Notes
Please provide a narrative responding to each of the items listed in your contract scope of services that were not addressed above.*
Please upload copies of outreach and marketing materials used during this reporting period. You may also attach other supporting documents such as sign-in sheets, photos, new MOUs with partners, etc.*
Drop files here or
Certification*
- By clicking this checkbox, I attest that the information provided is an accurate representation of our activities during the reporting period.
Name of Person Completing this form*
First Last
Email*

Date (mm/dd/yyyy)	Venue/Location (please include municipality)	# people present	Was Attendance Taken (yes/no)	Was NJDOH Strike Team Present (yes/no)	Notes

ELC Report Form

NEW ELC FORM 4-1-21

Getting Involved