NEW Outreach Tracking Sheet

NEW Outreach Tracking Form

These submissions are due the LAST WEDNESDAY of each month!
Name*
Email*
Are you logging administrative hours or outreach?*

Administrative hoursOutreach work
Please choose which grant you're reporting work for, if applicable

Rural Grant (2025)LOSGF GrantSOS 4.0OneOhio
General Questions

Answer these questions below regardless of what type of work you're logging
Date of work being reported*

MonthDayYear
Date
Number of hours worked*
Summary of work completed, event, and/or location*
Outreach-Specific Questions
Zip codes served (click + button to add another zip)*
Please select the option(s) that best describe the event*

Individual workTreatment and recoveryCommunity tablingOutreach with unhousedSpecial event (Pride, ODAD, etc)Educational trainingStreet-level outreachOther
Did today's event serve or focus on any of the following groups (check all that apply):*

BIPOC communityLBGTQIA+ communityUnsheltered or homelessRural AppalachiaUndocumented immigrantsLatinxNone of these groups
Supplies and Notes
Resources requested and/or provided (check all that apply):*

SOAR NarcanWound Care KitBBA CardsNon-SOAR NarcanSafe Snorting KitNUA CardsNarcan/Naloxone TrainingSafe Smoking Kit - PipesTourniquetsFTSSafe Smoking Kit - StemsCookersFTS TrainingSafe Injecting KitGlass BubblersXTSBooty Bumping KitGlass StemsXTS TrainingHygiene KitHeavy StemsSafe Use TrainingSafe Sex KitCrack PipesWound Care TrainingSyringesEmergency ContraceptionFlyersSharps ContainersNo Supplies GivenFree MealsFoilsSleeping bagsSocksHatsDeodorantHand/Feet WarmersPadsTampons
Number of people engaged with*
Number of people enrolled in BBA*
Number of individuals with wounds serviced*
# of FTS given*
# of XTS given*
# of free meals given*
# of SOAR Narcan/Naloxone given to individuals*
# of SOAR Narcan/Naloxone placed for emergency access (NaloxBox/Cabinet)*
# of Non-SOAR Narcan/Naloxone given*
# of known overdose reversals (other than first responders)*
# of individuals given Narcan/Naloxone training*
# of wound care kits given*
# of safe snorting kits given*
# of safe smoking kits given*
# of safe injecting kits given*
# of booty bumping kits given*
# of hygiene kits given*
# of safe sex kits given*
# of individual syringes given*
# of sharps containers given*
# of BBA cards given
Estimate if you can :-) No number required.
# of individual tourniquets given*
# of individual cookers given*
# of glass bubblers given*
# of glass stems given*
# of heavy stems given*
# of crack pipes given*
# of foils given*
# of emergency contraceptives given*
# of sleeping bags given*
# of pairs of socks given*
# of hats given*
Additional information about resources requested/provided not listed above
It's ok to leave this blank!
Please describe the interactions with any new and/or existing community partners*
Who you interacted with, SOAR services you got them linked with, resources provided, etc.
Any information about linkages to care that came up during your outreach?
It's ok to leave this blank!
Any additional notes?
It's ok to leave this blank!
Zip code checkboxes (For Kim's use)

45105451444561645618456504566045679456934569745801458024580445805458064580745808458094581745820458334585045854458874480544838448404484244848448594486444866448744488044003440044400544010440304403244041440474404844068440764408244084440854408844093440994570145710457114571645717457194572345732457354573945740457614576445766457774577845780457824581945865458694587045871458844588545888458954589643713437184371943759439024390543906439094391243916439274392843933439344393543937439404394243947439504395143967439724397743983439854510145115451184511945121451304513145154451674516845171450044501145012450134501445015450184502545026450424504345044450504505345055450564506145062450634506445067450694507144607446154462044631446394464444651446754300943044430474306043070430724307843083430844538943010453194532345341453444534945368453694537245501455024550345504455054550645102451034510645112451204512245140451454514745150451534515645157451584516045176452454510745113451144513845146451484515945164451664516945177439204394543962439684440844413444154442344427444314443244441444454445544460444904449244493446254463444665438034380543811438124382443828438364384343844438454482044825448274483344854448564486044881448874401744022440404407044101441024410344104441054410644107441084410944110441114411244113441144411544116441174411844119441204412144122441234412444125441264412744128441294413044131441324413344134441354413644137441384413944140441414414244143441444414544146441474414944178441814418544188441894419044191441924419344194441954419744198441994530345304453084532845331453324534645348453504535145352453584536245380453884539043512435194352043526435304353643549435564300343015430214303243035430614306543066430744308243240434384408944814448164482444839448464487044871430464310243105431074311243130431364314743148431504315443155431574316343106431284314243160430024300443016430174302643054430684306943081430854308643109431104311943123431254312643137431944319543196431984319943201432024320343204432054320643207432094321043211432124321343214432154321643217432184321943220432214322243223432244322643227432284322943230432314323243234432354323643251432604326543266432684327043271432724327943287432914329943502435154352143533435404355343558435674561445620456234563145643456584567445685456864402144023440244402644033440464406244064440654407244073440804408645301453054530745314453164532445335453704538445385453874543045431454324543345434454354372243723437254373243733437364374943750437554376843772437734377843780450014500245030450334504145051450524511145174452014520245203452044520545206452074520845209452114521245213452144521545216452174521845219452204522145222452234522445225452264522745228452294523045231452324523345234452354523645237452384523945240452414524245243452444524645247452484524945250452514525245253452544525545258452624526345264452674526845269452704527145273452744527545277452804529645298452994599944804458144581645839458404584145858458674586845881458894589045897433264334043345433464581045812458354583645843458594390743973439744397643981439844398643988446794469344695446994351043516435234352443527435324353443535435454354843550435554511045123451324513345135451424515545172431114312743135431384314443149431524315843006438044461044611446174462444628446334463744638446544466044661446874469044826448374484744850448514485544857448654488844889448904562145640456564569243901439034390843910439134391743925439264393043932439384393943941439434394443948439524395343961439634396443970439714300543011430144301943022430284303743048430504404544057440604406144077440814409244094440954409644097456194563845645456594566945675456784568045688456964300143008430134301843023430254302743030430314303343055430564305843062430714307343080430934309843721437404331043311433184331943324433314333343336433434334743348433574335843360440014401144012440284403544036440394404444049440504405244053440544405544074440904341243434435044352843537435424354743560435664357143601436034360443605436064360743608436094361043611436124361343614436154361643617436184362043623436354365243654436564365743659436604366143666436674368143682436974369943029431404314343151431534316244401444054440644416444224442944436444424444344449444514445244454444714450144502445034450444505445064450744509445104451144512445134451444515445554460944619446724330143302433064330743314433224333243335433374334143342433564421244215442334423544251442534425444256442584427344274442754428044281442824572045741457434576045769457704577145772457754577645779457834531045822458264582845846458604586245866458824588345312453174531845326453374533945356453594536145371453734537445383437164374743752437544375743786437894379343914439154393143946457344530945315453224532545327453424534345345453544537745400454014540245403454044540545406454084540945410454124541345414454154541645417454184541945420454224542345424454264542745428454294543745439454404544145448454494545445458454594546345469454704547545479454814548245490437284375643758437874331543317433204332143325433344333843349433504370143702437204372743734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Should be Empty:

NEW Outreach Tracking Form

General Questions

Outreach-Specific Questions

Supplies and Notes