New Jersey Department of Health

Division of Family Health Services

Office of Tobacco Control

AMERICAN CANCER SOCIETY (ACS) 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

American Cancer Society (ACS)	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

- Include ACS Relay for Life events, Grassroots Advocacy Trainings	Activity Type

R-	Recruitment Presentation

M-	Meeting to discuss selection

I-	IMAC meeting

G-	Grassroots Advocacy Training

L-	Relay for Life

(Place an X below)	Partner

1-	Co-facilitating grantee

2-	Chronic Disease Coalition Partner

3-	None

Total

Number

Attending	Has the municipality/ county been selected for pursuing an ordinance?
R	M	I	G	L
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:

Date	Increase Number of Callers

to NJ Quitline

- Advocate and secure expansion of Mayor’s Wellness Campaign and Sustainable NJ to include tobacco

- Promote expansion of Fax-to-Quit referrals among key stakeholders

- Collaborate with ACS communications and marketing to identify media opportunities among target populations

- Collaborate with MQC to enhance www.NJQuitline.org website	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	Summary
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:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Event:

Organization/Attendees:

Date	Preventing Initiation/

Securing Long-Term Abstinence

- Promote the NJ Quitline

- Additions/revisions/promotion of self-help resources through Website: www.NJQuitline.org

- Expand supporting role of Mayor’s Wellness Campaign and Sustainable NJ to community groups

- Continue to assist in dialogue with Medicaid, promote and track cessation rates through NJQL referrals

- Partner with PCLT to work with youth	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 applicable)	Earned

Media
Earned Media?	Type

P-Print

R-Radio

T-TV

W-Web

O-Other	Summary
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:

SECTION B – SUCCESSES / LESSONS LEARNED
Date	Increasing Capacity to Sustain NJ Tobacco

Control Efforts through NJ Breathes

- Assist with efforts to increase participation and support for statewide coalition

- Identify additional key stakeholders

- Continue to assume administrative role	Role

A- Attended

P- Presented

C- Committee Meeting

O- Other	Total

Number of

Participants at Quarterly Meeting	Agenda

Details
A	P	C	O
Event:

Event:

Event:

Event:

Event:

Event:

Event:

Event:

Event:

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

AMERICAN CANCER SOCIETY (ACS) MONTHLY ACTIVITY REPORT

(Continued)

OTC-1

NOV 13	Page 6 of 8 Pages.

NOV 13	Page 1 of 8 Pages.

OTC-1 ACS Monthly Activity Report

ewhite

2013-09-30

NJDOH