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* 1. Organization Name: 
(Example: P.S.305, Miami Dade County Public Schools)

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* 2. Program/ Awareness Campaign/ Committee/ Network name:   
(Example: Read to Learn Book Club, Reading Explorers)

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* 3. What is the Early Learning or Literacy Program/ Service/Instructional Support/ Awareness Campaign that your activity serves?

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* 4. If you selected OTHER above, please explain. Otherwise, please put N/A.

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* 5. What is your program/ awareness campaign's intended outcome? (please list all)

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* 6. If you selected OTHER above, please explain. Otherwise, please put N/A.

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* 7. What is your setting? (please list all)

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* 8. If you selected OTHER above, please explain.  Otherwise, please put N/A.

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* 9. What is your target population? (please select all that apply)

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* 10. If you selected OTHER above, please explain. Otherwise, please put N/A.

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* 11. How do you access this population?
Please be as specific as possible. 
(Example: enrollment in Nurse Family Partnership; enrollment in public school; performance on X assessment; voluntary sign-up through X; etc.).

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* 12. What is the # of people served in your program/ awareness campaign?

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* 13. If applicable, please break it down by target group (Example: 50 Children 0-2 years old, 300+ Children in kindergarten through 5th grade).  Otherwise, please put N/A. 

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* 14. What is your program/ awareness campaign's duration in terms of time? 
(For example: year-round, summer, other)

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* 15. If you selected OTHER above, please explain your program / awareness campaign' duration. Otherwise, please put N/A.

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* 16. What is the duration and frequency of your program/ awareness campaign or activity?

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* 17. If you selected OTHER above, please explain your program / awareness campaign's duration and frequency. Otherwise, please put N/A.

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* 18. What ages/grades are served in your program/ awareness campaign? (please select all that apply)

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* 19. If you selected OTHER above, please explain the ages served in your program (Example: parents only).  Otherwise, please put N/A. 

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* 20. Which areas does your program/ awareness campaign serve? (refer to distributed map; please select all that apply)

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* 21. Do you think your program/ activity goal is:  

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* 22. If you selected BOTH above, please explain your program goal/ awareness campaign. Otherwise, please put N/A.

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* 23. Is your program/ awareness campaign primarily:

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* 24. If you selected BOTH above, please explain. Otherwise, please put N/A.

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* 25. Please include the addresses of your sites where program services, or awareness activities are occurring.

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