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GENERAL COMMUNITY SITE SUMMARY FORM Thank you for participating in the We Can! program developed by the National Institutes of Health to enhance your community’s obesity prevention efforts. Please use this form to summarize your We Can! activities once your programming is completed. To do so, simply print, complete, and then fax this form to the National Heart, Lung, and Blood Institute (NHLBI) Health Information Center at (240) 629-3246. If you prefer to enter this information in an online form, please visit the “Get Involved” page on the We Can! Web site at http://wecan.nhlbi.nih.gov/get-involved/ Completing this form indicates your willingness to post your activities for public use. Before we can post your activities, you must identify yourself so that we can verify or clarify any information if necessary. NHLBI will use your personal information only in the ways indicated in our Privacy Statement at http://www.nhlbi.nih.gov/about/privacy.htm. Submissions that promote businesses or commercial activities or products will not be accepted. CONTACT INFORMATION * Denotes a required information * Primary Point of Contact: First Name Middle Initial Last Name Title: * Name of Organization / Coalition: Mailing Address: * Phone: Fax: * E-mail: Audiences reached through your We Can! Programming: (please check appropriate boxes) Youth Educators Parents Healthcare professionals African American populations Native American populations Asian populations Hispanic populations Inner city populations Suburban populations Rural populations Other: ___________________(please specify) Please indicate which curricula you used by checking the box next to the name of the curriculum; then complete the table for each curriculum you used. CATCH Kids Club How many times did you implement this curriculum? Where did each implementation take place? School classroom/grounds Community/Rec. center Faith-based community center Hospital Summer camp Other: _______________________ (please specify) When did you implement this program? Before school During school After school In the evening On the weekend All day (summer camp) Other: _______________________ (please specify) On average, how long (in weeks) did each implementation last? On average, how many youth were involved in each implementation? Do you plan to implement this curriculum again? Yes No What was easy about implementing this curriculum? What was hard about implementing this curriculum? We Can! General Community Site Summary Form 2 Media-Smart Youth: Eat, Think, and Be Active! How many times did you implement this curriculum? Where did each implementation take place? (e.g. after school on school grounds, at the local YMCA) School classroom/grounds Community/Rec. center Faith-based community center Hospital Summer camp Other: _______________________ (please specify) When did you implement this program? Before school During school After school In the evening On the weekend All day (summer camp) Other: _______________________ (please specify) On average, how long (in weeks) did each implementation last? On average, how many youth were involved in each implementation? Do you plan to implement this curriculum again? Yes No What was easy about implementing this curriculum? What was hard about implementing this curriculum? We Can! General Community Site Summary Form 3 Student Media Awareness to Reduce Television (S.M.A.R.T.) How many times did you implement this curriculum? Where did each implementation take place? (e.g. after school on school grounds, at the local YMCA) School classroom/grounds Community/Rec. center Faith-based community center Hospital Summer camp Other: _______________________ (please specify) When did you implement this program? Before school During school After school In the evening On the weekend All day (summer camp) Other: _______________________ (please specify) On average, how long (in weeks) did each implementation last? On average, how many youth were involved in each implementation? Do you plan to implement this curriculum again? Yes No What was easy about implementing this curriculum? What was hard about implementing this curriculum? We Can! General Community Site Summary Form 4 v We Can! Energize Our Families: Curriculum for Parents and Caregivers How many times did you implement this curriculum? Where did each implementation take place? (e.g. during lunch hour at an office, in a community center during children’s programming) School classroom/grounds Community/Rec. center Faith-based community center Hospital Workplace Other: _______________________ (please specify) When did you implement this program? In the evening During work/lunch break Before work After work On the weekend Other: _______________________ (please specify) On average, how long (in weeks) did each implementation last? On average, how many parents were involved in each implementation? Do you plan to implement this curriculum again? Yes No What was easy about implementing this curriculum? What was hard about implementing this curriculum? We Can! General Community Site Summary Form 5 Community Events In the table below, please describe a We Can! community event you conducted. Event Name: Dates of the event: Type of event: (Health Fair, Fitness Festival, etc.) Location of the event: (City and State) Description of the event: Target audience: Number of people in attendance: Event giveaways and promotional items: Event partners and their contributions: Please describe additional We Can! community events you hosted in the space below. We Can! General Community Site Summary Form 6 Overall We Can! Experience Help us improve the We Can! program by answering the following questions: 1) Do you plan to continue implementing We Can!? Yes No, but I would like to stay on the We Can! General Community Site listserv and We Can! in Action eNewsletter listserv in case I can implement in the future. No, please remove me from the We Can! General Community Site listserv and We Can! in Action eNewsletter 2) What did you like best about the program? Curricula:________________________________ (please specify) Promotion materials (handbook, brochure, poster, bracelet) Media materials (PSAs, radio scripts) Partnership materials (national partnership recognition, slideshow presentations) Knowledge Management (listserv notifications, eNewsletter, We Can! Rally (October 6-7, 2006)) Other: ______________________________________ Other: ______________________________________ 3) What materials would help you implement We Can! more effectively in your community? Curricula: ________________________________ (please specify) Promotion materials (handbook, brochure, poster, bracelet) Media materials (branded materials, PSAs, radio scripts) Partnership materials (national partnership recognition, slideshow presentation, partnership outreach letter) Knowledge Management (listserv notifications, eNewsletter, We Can! Rally (October 6-7, 2006)) Other: ______________________________________ Other: ______________________________________ 4) Would you recommend this program to a colleague? NHLBI would like to highlight We Can! community site activities in program materials to share ideas, successes and challenges. If we can share your experiences in We Can! web pages and eNewsletters, and other materials please check the box below. If you have any questions regarding this process, please contact the NHLBI Health Information Center by e-mail at nhlbiinfo@nhlbi.nih.gov or by phone at 301-5928573;TTY: 240-629-3255; or toll-free at 1-866-35-WECAN. I give permission to use the descriptions of community activities on this form in We Can! materials. You have now completed your Summary Form. Thank you for taking the time to complete this form and for participating in the We Can! program. Please fax your completed for the NHLBI Health Information Center at (240) 629-3246. We Can! General Community Site Summary Form 7