ATSDR Success Story Form

Attachment 4d. ATSDR Success Story Form (Word)

Form Approved

OMB No. 0923-0057

Exp. Date 07/31/2020

ATSDR estimates the average public reporting burden for this collection of information as 30 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-0057).

Success Story Form
Project or Site Name	[free text field]
Attachments	[file attachment link]
APPLETREE Is the success story from an APPLETREE partner?	[drop-down options] -Yes -No
Choose Safe Places Is the success story for the Choose Safe Places for Early Care and Education (CSPECE) program?	[drop-down options] -Yes -No
City	[free text field]
State	[drop-down options] -List of all 50 states
POC	[free text field]
Brief Summary In 1-3 sentences, give a brief summary of the success story.	[free text field]
Background In 140-250 words, describe relevant background of site or project. Include dates and who was involved.	[free text field]
Intervention/Action taken In 140-250 words, describe the solution, intervention, or action that was taken.	[free text field]
Accomplishment/impact In 140-250 words, describe the impacts, outcomes, and results of the actions that were taken.	[free text field]
Link Add a relevant link to the site or project, if applicant	[button to insert a hyperlink]