New Jersey Department of Health

Division of Family Health Services

Office of Tobacco Control

REGIONAL GRANTEE 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

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)	Coordinator/

Agency/IMAC

Participants	Details
A	P	C	O
Event/Activity:

Event/Activity:

Event/Activity:

Event/Activity:

Event/Activity:

Event/Activity:

Month	3. IMAC Membership	Number

H-	Health Officers

L-	Government Representatives Other

Y-	Youth

O-	Organizations

P-	Parents	IMAC

Leader-ship Board Established

Total Number

of MOUs	Total Number

of Letters of Support	Total Number

Of General Participants
H	L	Y	O	P	YES	NO
Name of Municipality/County

Name of Municipality/County

Name of Municipality/County

Name of Municipality/County

Name of Municipality/County

Name of Municipality/County

Name of Municipality/County

Name of Municipality/County

Name of Municipality/County

Name of Municipality/County

Name of Municipality/County

Name of Municipality/County

Date	4. Ordinance Passage Municipality/County	1st

Reading

Date	2nd

Reading

Date	Passage

(Yes or No)	Date

Enacted

Date	4. Ordinance Passage Municipality/County	1st

Reading

Date	2nd

Reading

Date	Passage

(Yes or No)	Date

Enacted

Date	4. Ordinance Passage Municipality/County	1st

Reading

Date	2nd

Reading

Date	Passage

(Yes or No)	Date

Enacted

Date	4. Ordinance Passage Municipality/County	1st

Reading

Date	2nd

Reading

Date	Passage

(Yes or No)	Date

Enacted

Date	4. Ordinance Passage Municipality/County	1st

Reading

Date	2nd

Reading

Date	Passage

(Yes or No)	Date

Enacted

Date	4. Ordinance Passage Municipality/County	1st

Reading

Date	2nd

Reading

Date	Passage

(Yes or No)	Date

Enacted

5.	Awareness Events

Total number of awareness events in grant year:

Date	Description of Awareness Event	Name of Municipality or County

6.	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

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

Regional Grantee Monthly Activity Report

(Continued)

OTC-4

OCT 13	Page 11 of 1 Pages.

OCT 13	Page 1 of 1 Pages.

OTC-4, Regional Grantee Monthly Activity Report

ewhite

2013-10-10

NJDOH