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Outreach Activities Monthly Report (NEAR)

Every month our WIC agency sends a report to the state office describing our local outreach efforts. It is important we capture all outreach activities being conducted by all WIC staff. If you have participated in an outreach event or have conducted outreach for your WIC clinic, please complete this form. Any questions regarding outreach and reporting, contact Carla Munoz, Outreach Coordinator.

Outreach in the community includes:

Health Fairs, community events, nutrition/breastfeeding workshops and classes, community meetings, phone calls or visits to physician offices, medical clinics, child care centers, health organizations, social service programs, health centers, and any other program/organization contacted regarding the WIC program.

Please note you only need to complete ONE (1) form per outreach event or activity. If you participated in an event with more than one WIC staff, only one needs to complete the form.

The WIC Outreach Request Form can be found on our external website. Click Here This form is to be completed by outside organizations requesting our participation in an outreach event or activity.

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your job title?

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* 4. Did you conduct this outreach with another staff member?

Yes

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* 5. Name of Additional Staff (First and Last Name):

Staff Member 1:

Staff Member 2:

Staff Member 3:

Staff Member 4:

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* 6. What date was the outreach conducted?

Date / Time

Date

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your job title?

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* 4. Did you conduct this outreach with another staff member?

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* 5. Name of Additional Staff (First and Last Name):

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* 6. What date was the outreach conducted?

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* 7. What type of outreach was conducted?