Community Health Worker
Monthly Report October 2023
Thank you for working to increase COVID-19 vaccination in high-risk, minority, and underserved communities across Tennessee in partnership with TCCN and TDH.
Please take 5-10 minutes to complete this survey. The form will allow you to save your progress and revisit if you cannot complete it in one sitting. We recommend saving the link to this survey and updating your responses periodically during the month. We also recommend using the same browser.
For the reporting period, did you participate in any TCCN or RHAT hosted webinars/conference calls/meetings, either in-person or via technology, relating to your work with the Community Health Worker initiative?
Yes
No
How many?
1
2
3+
Vaccine Support Services
TCCN partner Sostento has developed these activities for your use.
People Reached By Promotional Campaigns
*
Total Count
# of Social Media Likes
# of TV Impressions
# of Radio Impressions
# of Print Impressions (Flyers, Brochures)
# of Website Unique Views
# of Outdoor Impressions (Billboards)
# of Newsletter clicks
Promotional Campaigns File Upload
Please upload screenshots of social media posts, newsletter and website analytics or documents related to TV, radio or outdoor impressions, if applicable.
Promotional Campaigns File Upload
Promotional Campaigns File Upload
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Outreach and Events
Provide information about any CHW events you developed or participated in during the past month. Please include as much information as possible. Upload images or documents such as flyers, sign-in sheets, etc. Remember, you can save the progress of this form and return to it throughout the month.
Please tell us about Event 1:
Event 1
*
Total Count
Number of participants in this event
Number of individuals vaccinated
Number of rides provided
Number of future appointments coordinated
Event 1 File Upload
Please upload invitations, flyers, sign-in sheets and demographics summary.
Event 1 File Upload
Event 1 File Upload
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Please tell us about Event 2:
Event 2
*
Total Count
Number of participants in this event
Number of individuals vaccinated
Number of rides provided
Number of future appointments coordinated
Event 2 File Upload
Please upload invitations, flyers, sign-in sheets and demographics summary.
Event 2 File Upload
Event 2 File Upload
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Please tell us about Event 3:
Event 3
*
Total Count
Number of participants in this event
Number of individuals vaccinated
Number of rides provided
Number of future appointments coordinated
Event 3 File Upload
Please upload invitations, flyers, sign-in sheets and demographics summary.
Event 3 File Upload
Event 3 File Upload
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Please tell us about Event 4:
Event 4
*
Total Count
Number of participants in this event
Number of individuals vaccinated
Number of rides provided
Number of future appointments coordinated
Event 4 File Upload
Please upload invitations, flyers, sign-in sheets and demographics summary.
Event 4 File Upload
Event 4 File Upload
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Do you have any additional events that occurred during the reporting period? If yes, we will send you an additional form to complete so that all data can be captured.
Yes
No
Please share any SUCCESSES you had over the past month, if applicable:
Please share any CHALLENGES you had over the past month and how you overcame them, if applicable:
Please report any additional vaccinations resulting from CHW outreach efforts this month not reported above.
Is there a patient success story that you would like to share? Please do not provide any personally identifiable information.
From the list of populations below, please select ALL types of populations targeted by your organization in the past month.
Racial and Ethnic Groups
Black/African American
White
Asian
Native Hawaiian/Pacific Islander
Hispanic/Latino
Communities with High Social Vulnerability Index (SVI)
Rural Communities
Disabled
Homebound/Isolated
Uninsured/Underinsured
Immigrants/Refugees
Limited Transportation
From the list of communities below, please select ALL types of communities targeted by your organization in the past month.
High rates of COVID-19 infection, severe disease or death
High rates of underlying health conditions placing them at greater risk for severe COVID-19 disease
Likely to experience barriers accessing vaccination services
Low acceptance of or confidence in COVID-19 vaccines
Where COVID-19 mitigation measures have not been widely adopted
With historically low adult vaccination rates
With a history of mistrust in health authorities or the medical establishment
Those not well-known to health authorities or those which have not traditionally been the focus of immunization program
Number of partners engaged by your organization during the past month.
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