Community Outreach Event Feedback Form

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Congratulations on completing your community outreach event! Please use this form to report your event details to National APAMSA so that we may publicize the hard work you accomplished. If you have photos/other media you would like to share, please email these to outreach@apamsa.org.

If you received funding through the National APAMSA Community Outreach Grant, you are required to fill out this form no later than 2 weeks post event. The information you provide helps us improve our process for funding and report information to the All of Us Research Program as our grant sponsor.

Any questions can be directed to the Community Outreach Director at outreach@apamsa.org.

Email *

Name *

School/Chapter Name *

Event Name *

Event Date *

YYYY

Event Venue/Location(s) (exact name and address, if virtual state platform used) *

Event Start Time *

Time

Event End Time *

Time

Number of medical students (or other healthcare students) involved *

Number of community members served *

Or number of participants you introduced the All of Us Program to during your outreach event/research study. *This can be estimated*

Target/Primary Population *

Black, African or African American

American Indian or Alaska Native

East Asian

South Asian

Southeast Asian

Income - High

Income - Middle

Income - Low

Hispanic, Latino or Spanish (H/L/S)

Middle Eastern or North African (MENA)

Native Hawaiian or Other Pacific Islander (NHPI)

Older Adults

Rural

Sexual and Gender Minorities (LGBTQ+)

White/Caucasian

Other:

Required

Did you receive funding through the National APAMSA Community Outreach Grant? *

Yes

Have you already submitted your photos to National APAMSA? Or emailed them to outreach@apamsa.org? If not, please provide a link to a Google Drive/Photos folder here. *

For promotional purposes, please include the handles/account names for your APAMSA chapters' social media profiles (i.e. Instagram, Facebook, Twitter) if you would like us to share your stories.

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