Name of activity:_______________________________________________________________
Date(s):______________________________________________________________________
One-time event:_______________ Ongoing activity:______________ Length:____________
Lcation: ___________________________ Target audience:___________________________
Goals:_______________________________________________________________________
What inspired you to plan this activity?_______________________________________________
Your role:_____________________________________________________________________
____________________________________________________________________________
Your partner (s) and their role (s):__________________________________________________
____________________________________________________________________________
Resources used:______________________________________________________________
____________________________________________________________________________
How did you promote the activity?__________________________________________________
Number of participants:_________________________________________________________
Did you get feedback from participants?
Yes
No If yes, what did they say?_______
___________________________________________________________________________
How do you feel about what you did? ______________________________________________
Would you do it again?
Yes
No
What would you do differently?___________________________________________________
What tips do you have for other women who are interested in your activity idea? ____________
____________________________________________________________________________
Name: ______________________________________________________________________
Address: ____________________________________________________________________
____________________________________________________________________________
Telephone number:________________ E-mail address:_____________________________
Send your success story to:
Bright Futures for Women’s Health and Wellness
Health Resources and Services Administration
Office of Women’s Health
U.S. Department of Health and Human Services
5600 Fishers Lane
Rockville, MD 20857
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