New Jersey Department of Health

Division of Family Health Services

Office of Tobacco Control

MOM’S QUIT CONNECTION (MQC) 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

Mom’s Quit Connection (MQC)	Grant Number

Quarter Number

Date of Report (Month/Year)

SECTION A - ACTIVITY
Date	As IMAC technical advisor and co‑facilitator for regional partner, indicate:

- Event attended

- Municipality/County

- Role/Responsibility @ mtg

- Plans/Ordinance Process	Activity Type

R-	Recruitment Presentation

M-	Meeting to discuss selection

I-	IMAC meeting

K-	Key Stakeholder Presentation

O-	Other

(Place an X below)	Partner

1-	Co-facilitating grantee

2-	Chronic Disease Coalition Partner

3-	None

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:

Date	Increase Number of Callers

to NJ Quitline

- Targeted Provider Campaigns	How Promoted

M-	Multi-media Presentation

W-Webinar

O-	Other

P-	Promotional Materials

T-	Training/TA provided

(Place an X below)	Total

Number

Attending	Earned

Media
Generated	Type

P-Print

R-Radio

T-TV

W-Web

O-Other	Describe
M	W	O	P	T
YES	NO	P	R	T	W	O
Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Date	Increase Number of Callers

to NJ Quitline

- Family Cessation Model	How Promoted

M-	Multi-media Presentation

W-Webinar

O-	Other

P-	Promotional Materials

T-	Training/TA provided

(Place an X below)	Total

Number

Attending	Earned

Media
Generated	Type

P-Print

R-Radio

T-TV

W-Web

O-Other	Describe
M	W	O	P	T
YES	NO	P	R	T	W	O
Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Date	Promoting Long-Term Abstinence

- Promoting the NJ Quitline

- Additions/Revisions/Promotion of self-help resources through website www.NJQuitline.org

- Other Activities	How Promoted/

Resources Utilized

M-	Multi-media Presentation

W-Webinar

O-	Other

P-	Promotional Materials

T-	Training/TA provided

(Place an X below)	Total

Number

Attending (if applies)	Earned

Media
Earned Media Generated	Type

P-Print

R-Radio

T-TV

W-Web

O-Other	Describe
M	W	O	P	T
YES	NO	P	R	T	W	O
Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Date	Participation and Support

for NJ Breathes

Statewide Coalition	Role

A-	Attended

P-	Presented

C-	Committee Meeting

O-	Other

(Place an X below)	MQC

Participants	Details
A	P	C	O
Event/Activity:

Event/Activity:

Event/Activity:

Event/Activity:

Event/Activity:

Event/Activity:

ADDITIONAL ACTIVITIES
Description of Event:

Description of Event:

Description of Event:

Description of Event:

Description of Event:

Description of Event:

Description of Event:

Description of Event:

Description of Event:

Description of Event:

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

SECTION C - SIGNATURES
Signature of Executive Director	Date
Signature of Regional Coordinator	Date
NJDOH Review	Date

MOM’S QUIT CONNECTION (MQC) MONTHLY ACTIVITY REPORT

(Continued)

OTC-3

NOV 13	Page 8 of 8 Pages.

NOV 13	Page 1 of 8 Pages.

OTC-3 MQC Monthly Activity Report

ewhite

2013-09-30

NJDOH