New Jersey Department of Health

Division of Family Health Services

Office of Tobacco Control

GASP MONTHLY ACTIVITY REPORT

Instructions:

This report is to be completed referencing the current Administrative Guidelines to Attachment C; all definitions and/or explanations can be obtained there. This entire report must be completed (typed); if a section is left blank, please provide the reason on the report. If additional space is needed for any section, please feel free to attach additional pages. Please remember to attach all required supporting documents; in addition, for clarity, you may attach any unrequired supporting documents and/or information. When complete, please be sure that all appropriate signatures are provided.

Agency

Grant Number

Quarter Number

Date of Report (Month/Year)

SECTION A - ACTIVITY
Date	1.	Meetings as IMAC technical advisor and co‑facilitator for regional partner, indicate:

- Event attended

- Municipality/County

- Role/Responsibility @ mtg

- Plans/Ordinance Process

- Municipality/County Selection/ Recruitment Plans/Ordinance Process	Activity Type

R-	Recruitment Presentation

M-	Meeting to discuss selection

I-	IMAC meeting

K-	Key Stakeholder/ Hearing Presentation

O-	Other

(Place an X below)	Partner

1-	Co-facilitating grantee

2-	Chronic Disease Coalition Partner

3-	None

Approximate

Total Number of People

Present	Has the municipality/ county been selected for pursuing an ordinance?
R	M	I	K	O
YES	NO
Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Name of Municipality/County

Brief Description of Activity:

Date	2.	Participation and Support

for NJ Breathes

Statewide Coalition	Role

A-	Attended

P-	Presented

C-	Committee Meeting

O-	Other

(Place an X below)	GASP

Participants	Details
A	P	C	O
Event/Activity:

Event/Activity:

Event/Activity:

Event/Activity:

Event/Activity:

Event/Activity:

3.	Technical Assistance Requested by Municipalities/Counties (ordinances)

Total number of requests for technical assistance from municipalities/counties:

Date	Description of Technical Assistance Provided	Name of Municipality or County

4	Presentations Regarding Various Tobacco Control Related Topics

Total number of presentations regarding various tobacco control related topics:

Date	Description of Presentations	Name of Municipality or County

5.	Earned Media

Total number of earned media:

Date	Description of Media	Media Type

N – Newspaper

T – Television

R – Radio

W - Website
N	T	R	W

6.	Consultations

Total number of consultations:
NOTE: Please attach consultation categories breakdown.

7.	Website Updates / Revisions / White Papers

Total number of website updates/revisions:

Date	Description of Website Updates/Revisions/White Papers	Name of Municipality or County

SECTION B – SUCCESSES / LESSONS LEARNED
1. Describe Progress:

2. Facilitating Factors of Success:

3. Barriers/Issues Encountered:

4. Plans to Overcome Barriers/Issues Encountered:

5. Unanticipated Outcomes Resulting from the Objective

SIGNATURES
Signature of Executive Director	Date
Signature of Regional Coordinator	Date
NJDOH Review	Date

GASP Monthly Activity Report

(Continued)

OTC-2

OCT 13	Page 12 of 12 Pages.

OCT 13	Page 1 of 12 Pages.

OTC-2 GASP Monthly Activity Report

ewhite

2013-10-10

NJDOH