University of Texas - College of Pharmacy

Event Documentation Form

Instructions:
Please fill out the every blank. Enter N/A in spaces that do not apply.

Committee Name:
Activity:
Date:
Location:
Target Audience:
Event Coordinator:
Coordinator Email:
Coordinator Phone:
Promotional Materials Used: (please indicate who donated the materials)

Other ASP Committees Involved:

Other Organizations Involved:

Statistical Information:

Total number of hours spent planning:
Total number of hours spent at event:
Estimated number of patients reached through public relations: (promotions, announcements, etc.)
Number of participants attending overall event:
Number of patients/participants at area of activity:
Number of patients screened:
Number of patients educated:
Number of student pharmacists involved:
Number of faculty involved in this event:
Number of non-faculty pharmacists involved:

For Operation Diabetes only:

Number of patients referred to a physician:

For Heartburn Awareness Committee only:

Number of patients with episodic heartburn:
Number of patients with frequent heartburn:
Number of patients with severe or persistent heartburn:

For Vial of Life Committee only:

How many vials were distributed at this event?

Brief Synopsis : (Provide a brief description of your event. How and why was it successful? Please describe examples of specific patients that especially benefited from the information or service that your committee presented to them or in which a patient was especially thankful for the information/service provided.)

Measure of Success : Provide an explanation of how this event meets the committee goals and the goals of UT-APhA-ASP(Education and Collaboration).

Pictures: Pictures should be emailed to thomasbarber@mail.utexas.edu or yaserxgadit@hotmail.com. (Pictures that include patients and committee members interacting are preferred. Please include a caption for each picture that lists the names and year in pharmacy school for each committee member in the picture.) Supplemental information: Supplemental information should be emailed to thomasbarber@mail.utexas.edu or yaserxgadit@hotmail.com. (Supplemental information consists of original documents, newsletters, questionnaires or brochures created by your committee. You may also include copies of special advertising for your event such as an article written about the event or committee in The Daily Texan or a local newspaper.)

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Last Reviewed: June 29, 2009