COMMIT Coalition In-Kind Tracking Form

Thank you for your help!

Please return completed forms by the 1^st of the next month to:

Meredith Slaymaker (ASAC), Fax (319) 390-3513

 

Name			Organization
Description of Services			County
Date of Service			Circle Topic Secondhand Smoke         Cessation         General Prevention
TIME (Figure time to the nearest .5 hour.  Adults = $30.00/Hour;   Students = $8.50/Hour)
Type	Hours	$	Type	Hours	$
Coalition Meeting			Faxes
Other Meeting			E-mail & Phone Calls
General “Prep” Time
Education/Cessation			Travel Time
Health Fair			Other:
SUPPLIES
Type	#	$	Type	#	$
Facilities	N/A		Pens, Pencils, Markers
Copies (.05 each)			Incentives, Prizes
Postage			Food/Beverage
Envelopes			Other:
Binders/Folders			Other:
MILEAGE
Miles	X .34 =	$
TOTAL = $

 

 

__________ NUMBER OF ADULTS PRESENT                              

__________ NUMBER OF YOUTH (Ages 0 – 17) PRESENT

 

 

X______________________________                          _______________ 

Signature                                                                                 Date

 

______________________________                             _______________

Coalition Representative                                                         Date