Outreach Tracking Form
These submissions are due the LAST WEDNESDAY of each month!
Name
*
Please Select
Tonja Catron
Holly Woodruff
Jessica Collier
Jamie Decker
Sharona Bishop
Abby Spears
Jordan Mays
Rontae Bass
Jayson Jarvis
TEST
Email
*
Please Select
tonja@thesoarinitiative.org
holly@thesoarinitiative.org
jessicacollier@thesoarinitiative.org
jamie@thesoarinitiative.org
sharona@thesoarinitiative.org
abby@thesoarinitiative.org
jordan@thesoarinitiative.org
Rontae@thesoarinitiative.org
jayson@thesoarinitiative.org
TEST
kim@thesoarinitiative.org
How many events/locations are you logging today?
*
One
Multiple
Is this report related to work for the Troy Foundation Grant?
*
Yes
No
Is this report related to work for the Rural Outreach Grant?
*
Yes
No
Are you reporting administrative hours, or hours related to outreach work?
*
Administrative hours (training, meetings, reporting)
Outreach work
Back
Next
Event
Date of event
*
 /
Month
 /
Day
Year
Date
Event and/or location
*
Zip codes served (click + button to add another zip)
*
Please select the option(s) that best describe the event
*
Individual work
Treatment and recovery
Community tabling
Outreach with unhoused
Special event (Pride, ODAD, etc)
Educational training
Street-level outreach
Other
Did today's event serve or focus on any of the following groups (check all that apply):
*
BIPOC community
LBGTQIA+ community
Unsheltered or homeless
Rural Appalachia
Undocumented immigrants
Latinx
None of these groups
Back
Next
Rural Specific Questions
Number of Hours
*
For example if you worked 1hr 45min, enter it as 1.75
Summary of Service
*
Back
Next
Supplies and Notes
Resources requested and/or provided (check all that apply):
*
Booty bumping kits
Cookers
Crack pipes
DBA cards
Flyers
Foils
FTS
FTS training
Free meals
Glass bubblers
Glass stems
Heavy stems
Hygiene kits
SOAR Narcan
Naloxone/Narcan training
Non-SOAR Narcan
NUA cards
Safe injection kits
Safe sex kits
Safe smoking kits
Safe snorting kits
Safe use training
Sharps containers
Syringes
Tourniquets
Wound care kits
Wound care training
XTS
XTS training
No supplies given
Number of people engaged with
*
Number of people enrolled in DBA
*
Number of individuals with wounds serviced
*
# of FTS given
*
# of XTS given
*
# of SOAR Narcan/Naloxone given to individuals
*
# of SOAR Narcan/Naloxone placed for emergency access (NaloxBox/Cabinet)
*
# of individuals given Narcan/Naloxone training
*
# of known reversals (other than first responders)
*
# of Non-SOAR Narcan/Naloxone given
*
# of wound care kits given
*
# of individual syringes given
*
# of glass stems given
*
# of glass bubblers given
*
# of heavy stems given
*
# of crack pipes given
*
# of foils given
*
# of individual cookers given
*
# of individual tourniquets given
*
# of sharps containers given
*
# of DBA cards given
*
# of free meals given
*
# of booty bumping kits given
*
# of safe snorting kits given
*
# of safe injecting kits given
*
# of hygiene kits given
*
# of safe smoking kits given
*
# of safe sex kits given
*
Additional information about resources requested/provided not listed above
Last Question!
Any additional notes?
Zip code checkboxes (For Kim's use)
45105
45144
45616
45618
45650
45660
45679
45693
45697
45801
45802
45804
45805
45806
45807
45808
45809
45817
45820
45833
45850
45854
45887
44805
44838
44840
44842
44848
44859
44864
44866
44874
44880
44003
44004
44005
44010
44030
44032
44041
44047
44048
44068
44076
44082
44084
44085
44088
44093
44099
45701
45710
45711
45716
45717
45719
45723
45732
45735
45739
45740
45761
45764
45766
45777
45778
45780
45782
45819
45865
45869
45870
45871
45884
45885
45888
45895
45896
43713
43718
43719
43759
43902
43905
43906
43909
43912
43916
43927
43928
43933
43934
43935
43937
43940
43942
43947
43950
43951
43967
43972
43977
43983
43985
45101
45115
45118
45119
45121
45130
45131
45154
45167
45168
45171
45004
45011
45012
45013
45014
45015
45018
45025
45026
45042
45043
45044
45050
45053
45055
45056
45061
45062
45063
45064
45067
45069
45071
44607
44615
44620
44631
44639
44644
44651
44675
43009
43044
43047
43060
43070
43072
43078
43083
43084
45389
43010
45319
45323
45341
45344
45349
45368
45369
45372
45501
45502
45503
45504
45505
45506
45102
45103
45106
45112
45120
45122
45140
45145
45147
45150
45153
45156
45157
45158
45160
45176
45245
45107
45113
45114
45138
45146
45148
45159
45164
45166
45169
45177
43920
43945
43962
43968
44408
44413
44415
44423
44427
44431
44432
44441
44445
44455
44460
44490
44492
44493
44625
44634
44665
43803
43805
43811
43812
43824
43828
43836
43843
43844
43845
44820
44825
44827
44833
44854
44856
44860
44881
44887
44017
44022
44040
44070
44101
44102
44103
44104
44105
44106
44107
44108
44109
44110
44111
44112
44113
44114
44115
44116
44117
44118
44119
44120
44121
44122
44123
44124
44125
44126
44127
44128
44129
44130
44131
44132
44133
44134
44135
44136
44137
44138
44139
44140
44141
44142
44143
44144
44145
44146
44147
44149
44178
44181
44185
44188
44189
44190
44191
44192
44193
44194
44195
44197
44198
44199
45303
45304
45308
45328
45331
45332
45346
45348
45350
45351
45352
45358
45362
45380
45388
45390
43512
43519
43520
43526
43530
43536
43549
43556
43003
43015
43021
43032
43035
43061
43065
43066
43074
43082
43240
43438
44089
44814
44816
44824
44839
44846
44870
44871
43046
43102
43105
43107
43112
43130
43136
43147
43148
43150
43154
43155
43157
43163
43106
43128
43142
43160
43002
43004
43016
43017
43026
43054
43068
43069
43081
43085
43086
43109
43110
43119
43123
43125
43126
43137
43194
43195
43196
43198
43199
43201
43202
43203
43204
43205
43206
43207
43209
43210
43211
43212
43213
43214
43215
43216
43217
43218
43219
43220
43221
43222
43223
43224
43226
43227
43228
43229
43230
43231
43232
43234
43235
43236
43251
43260
43265
43266
43268
43270
43271
43272
43279
43287
43291
43299
43502
43515
43521
43533
43540
43553
43558
43567
45614
45620
45623
45631
45643
45658
45674
45685
45686
44021
44023
44024
44026
44033
44046
44062
44064
44065
44072
44073
44080
44086
45301
45305
45307
45314
45316
45324
45335
45370
45384
45385
45387
45430
45431
45432
45433
45434
45435
43722
43723
43725
43732
43733
43736
43749
43750
43755
43768
43772
43773
43778
43780
45001
45002
45030
45033
45041
45051
45052
45111
45174
45201
45202
45203
45204
45205
45206
45207
45208
45209
45211
45212
45213
45214
45215
45216
45217
45218
45219
45220
45221
45222
45223
45224
45225
45226
45227
45228
45229
45230
45231
45232
45233
45234
45235
45236
45237
45238
45239
45240
45241
45242
45243
45244
45246
45247
45248
45249
45250
45251
45252
45253
45254
45255
45258
45262
45263
45264
45267
45268
45269
45270
45271
45273
45274
45275
45277
45280
45296
45298
45299
45999
44804
45814
45816
45839
45840
45841
45858
45867
45868
45881
45889
45890
45897
43326
43340
43345
43346
45810
45812
45835
45836
45843
45859
43907
43973
43974
43976
43981
43984
43986
43988
44679
44693
44695
44699
43510
43516
43523
43524
43527
43532
43534
43535
43545
43548
43550
43555
45110
45123
45132
45133
45135
45142
45155
45172
43111
43127
43135
43138
43144
43149
43152
43158
43006
43804
44610
44611
44617
44624
44628
44633
44637
44638
44654
44660
44661
44687
44690
44826
44837
44847
44850
44851
44855
44857
44865
44888
44889
44890
45621
45640
45656
45692
43901
43903
43908
43910
43913
43917
43925
43926
43930
43932
43938
43939
43941
43943
43944
43948
43952
43953
43961
43963
43964
43970
43971
43005
43011
43014
43019
43022
43028
43037
43048
43050
44045
44057
44060
44061
44077
44081
44092
44094
44095
44096
44097
45619
45638
45645
45659
45669
45675
45678
45680
45688
45696
43001
43008
43013
43018
43023
43025
43027
43030
43031
43033
43055
43056
43058
43062
43071
43073
43080
43093
43098
43721
43740
43310
43311
43318
43319
43324
43331
43333
43336
43343
43347
43348
43357
43358
43360
44001
44011
44012
44028
44035
44036
44039
44044
44049
44050
44052
44053
44054
44055
44074
44090
43412
43434
43504
43528
43537
43542
43547
43560
43566
43571
43601
43603
43604
43605
43606
43607
43608
43609
43610
43611
43612
43613
43614
43615
43616
43617
43618
43620
43623
43635
43652
43654
43656
43657
43659
43660
43661
43666
43667
43681
43682
43697
43699
43029
43140
43143
43151
43153
43162
44401
44405
44406
44416
44422
44429
44436
44442
44443
44449
44451
44452
44454
44471
44501
44502
44503
44504
44505
44506
44507
44509
44510
44511
44512
44513
44514
44515
44555
44609
44619
44672
43301
43302
43306
43307
43314
43322
43332
43335
43337
43341
43342
43356
44212
44215
44233
44235
44251
44253
44254
44256
44258
44273
44274
44275
44280
44281
44282
45720
45741
45743
45760
45769
45770
45771
45772
45775
45776
45779
45783
45310
45822
45826
45828
45846
45860
45862
45866
45882
45883
45312
45317
45318
45326
45337
45339
45356
45359
45361
45371
45373
45374
45383
43716
43747
43752
43754
43757
43786
43789
43793
43914
43915
43931
43946
45734
45309
45315
45322
45325
45327
45342
45343
45345
45354
45377
45400
45401
45402
45403
45404
45405
45406
45408
45409
45410
45412
45413
45414
45415
45416
45417
45418
45419
45420
45422
45423
45424
45426
45427
45428
45429
45437
45439
45440
45441
45448
45449
45454
45458
45459
45463
45469
45470
45475
45479
45481
45482
45490
43728
43756
43758
43787
43315
43317
43320
43321
43325
43334
43338
43349
43350
43701
43702
43720
43727
43734
43735
43738
43746
43762
43767
43771
43777
43791
43802
43821
43822
43830
43842
43711
43717
43724
43779
43788
45727
43408
43416
43430
43432
43433
43436
43439
43440
43445
43446
43449
43452
43456
43458
43468
45813
45821
45849
45851
45855
45861
45873
45879
45880
43076
43730
43731
43739
43748
43760
43761
43764
43766
43782
43783
43103
43113
43116
43117
43145
43146
43156
43164
45613
45624
45642
45646
45661
45683
45687
45690
44201
44202
44211
44231
44234
44240
44241
44242
44243
44255
44260
44265
44266
44272
44285
44288
44411
44412
45003
45070
45311
45320
45321
45330
45338
45347
45378
45381
45382
45815
45827
45830
45831
45837
45844
45848
45853
45856
45864
45875
45876
45877
45893
44813
44822
44843
44862
44875
44878
44901
44902
44903
44904
44905
44906
44907
44999
43101
43115
45601
45612
45617
45628
45633
45644
45647
45673
45681
43407
43410
43420
43431
43435
43442
43464
43469
44811
45629
45630
45636
45648
45652
45653
45657
45662
45663
45671
45677
45682
45684
45694
45699
44802
44807
44809
44815
44818
44828
44830
44836
44841
44845
44853
44861
44867
44883
45302
45306
45333
45334
45336
45340
45353
45360
45363
45365
45367
45845
44601
44608
44613
44614
44626
44630
44632
44640
44641
44643
44646
44647
44648
44650
44652
44657
44662
44666
44669
44670
44688
44689
44701
44702
44703
44704
44705
44706
44707
44708
44709
44710
44711
44714
44718
44720
44721
44730
44735
44750
44767
44799
44056
44067
44087
44203
44210
44216
44221
44222
44223
44224
44232
44236
44237
44250
44262
44264
44278
44286
44301
44302
44303
44304
44305
44306
44307
44308
44309
44310
44311
44312
44313
44314
44315
44316
44317
44319
44320
44321
44322
44325
44326
44328
44333
44334
44372
44393
44396
44398
44399
44685
44402
44403
44404
44410
44417
44418
44420
44424
44425
44428
44430
44437
44438
44439
44440
44444
44446
44450
44453
44470
44473
44481
44482
44483
44484
44485
44486
44488
44491
43832
43837
43840
44612
44621
44622
44629
44653
44656
44663
44671
44678
44680
44681
44682
44683
44697
43007
43036
43040
43041
43045
43064
43067
43077
43344
45832
45838
45863
45874
45886
45891
45894
45898
45899
45622
45634
45651
45654
45672
45695
45698
45005
45032
45034
45036
45039
45040
45054
45065
45066
45068
45152
45162
45712
45713
45714
45715
45721
45724
45729
45742
45744
45745
45746
45750
45767
45768
45773
45784
45786
45787
45788
45789
44214
44217
44230
44270
44276
44287
44606
44618
44627
44636
44645
44659
44667
44676
44677
44691
43501
43505
43506
43517
43518
43531
43543
43554
43557
43570
43402
43403
43406
43413
43414
43437
43441
43443
43447
43450
43451
43457
43460
43462
43463
43465
43466
43467
43511
43522
43525
43529
43541
43551
43552
43565
43569
43619
44817
45872
43316
43323
43330
43351
43359
44844
44849
44882
Submit
Should be Empty: