IUH Event Coordinator Summary

IUH Coordinator Event Summary

Please complete this form and submit.

Event Date*
MM slash DD slash YYYY
Event Number (ex: 12345)*
Client*
This field is hidden when viewing the form
Client*
Event Location*
Lead Staff Name*
Who was your TotalWellness Account Manager?*
Number of screening participants*
Please enter a number from 0 to 9999.
Number of walk-in participants*
Number of no-shows*
Did all participants complete the Mental Health Survey?*
Please provide names and explanations:
Were you able to obtain a blood sample from ALL participants?*
Please provide names and explanations:
Did you have any participants with critical values?*
Please provide names and explanations (what the value was, any symptoms displayed and what your directions were for the patient):
Did the event start on time?*
Please provide start time and explanation:
Did the event end on time?*
Please provide end time and explanation:
Overall Participant Feedback*
Who was your Site Contact?*
Issues that affected the outcome of the event (IE. Missing supplies, staff issues, large number of re-sticks, Afinion error codes, A1c tests wasted, etc.)
Overall success:*
Did you utilize iPads to collect data on-site?*
- Yes
- No
Did you use Screening consent forms that were not entered into the iPads?*
- Yes
- No
How many paper Screening consent forms were not entered into the iPad?
Please overnight all paperwork using our Fed Ex overnight Account Number: 227999381
Please return paperwork (time logs, satisfaction surveys, etc.) via Fed Ex ground with your supplies.

If you are keeping supplies longer than a week, please send all paperwork via Fed Ex Ground once a week at minimum.
If you collected data onsite using an iPad, please upload the documents listed below.
Time Log - Page 1*
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 50 MB.
Time Log - Page 2
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 50 MB.
Time Extension Form - If Applicable
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 50 MB.
FedEx Tracking #