IUH Health Plans Coordinator Event Summary Please complete this form and submit. Event Date* MM slash DD slash YYYY Event Number (ex: 12345)*Client Name*This field is hidden when viewing the formClient Name*AE BoyceAgBestAnderson UniversityAuthor SolutionsBaumgartner and CompanyBauer Family ResourcesBloomington Public TransitChristel House AcademyCity of MuncieCity of Muncie FirefightersCity of TiptonClinton CountyConner PrairieCurry AutoDecatur TownshipFaith MinistriesFamily Development ServicesFerrer MechanicalIndiana Symphony SocietyInteg Health System, P.C.Jay CountyJewish Federation of Greater IndianapolisLawrence CountyMonroe Fire Protection ServicesMorris MachineMt. VernonMuncie Indiana Transit SystemMursixNTN Driveshaft Inc.Owen County GovernmentOwen County State BankPlatechProKidsPRD D&MPutnam CountyRiley FoundationRoyal MotorsSharpen TechnologiesSisters of ProvidenceStalcopSt. Anthony HealthcareStone Belt ArcStone City ProductsStorage ExpressStrategic Insurance TrustSumcoSunset HarborTKO GraphixTown of EllettsvilleVaseyWalnut Street TrustWesley Manor Retirement CommunityEvent Location*Lead Staff Name*Who was your TotalWellness Account Manager?*Jessica RetzlaffNumber of screening participants*Please enter a number from 0 to 9999.Number of walk-ins*Please enter a number from 0 to 9999.Number of no-shows*Please enter a number from 0 to 9999.Did all participants complete the MH Survey?*YesNoIf no, please provide names and explanation:Did the event start on time?*YesNoPlease provide start time and explanation:Did the event end on time?*YesNoPlease provide end time and explanation:Overall Participant Feedback*Site Contact Name and Feedback:*Issues that affected the outcome of the event (IE. Missing supplies, staff issues, large number of re-sticks, etc.)Overall success:*Did you utilize iPads to collect data electronically on-site?* Yes No Did you use paper Screening consent forms that were not entered into the iPad?* 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 2Accepted 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.