Pathfinder Activity Report (PAR)
Please answer the following questions to the best of your ability. Ample space is provided for additional comments. If you would like to include back-up materials with your report, please send them to us via e-mail.
* Denotes Required Field
Part A - Your Information
Report for the Month/Year of:
Part B - Individuals/Families Assisted
Race/Ethnicity (if known, enter number or percent):
African-American
Caucasian
Name:
E-Mail:
Phone:
Pathfinder City or Region:
Special Event (Include Name of Event and Date, plus complete Part C):
Native American
Asian
Hispanic
Other/Unknown
Age of person with facial difference (if known, enter number or percent):
Unborn
Birth to six months
7 - 12 Months
1 - 3 Years
4 - 5 Years
Elementary School
Types of assistance provided (mark with "X" all that apply):
Support by Phone
Middle School
High School
Adult 18 - 24
Adult 25 - 34
Adult 35 - 44
Adult 45 - 54
Adult 55 - 64
Adult 65+
Support by E-Mail
Pathfinder Packet
Met with Family
Pathfinder Referral
Other Referral
Total number assisted:
Did you provide a birthing hospital, cleft/craniofacial team, ultrasound facility or other medical professional with Pathfinder packets or other information during this reporting period?
Yes
No
If yes, please provide contact information:
Name:
Facility:
Address:
City, State, Zip:
Phone:
Did you provide a school or school district with any program materials during this reporting period?
Yes
No
If yes, please provide contact information:
Name:
Facility:
Address:
City, State, Zip:
Phone:
Number of Packets Distributed
Number of Packets Distributed
Did you attend Pathfinder training during this reporting period?
Yes
Teleconference
No
Live Workshop
Personal Training
Did you interact with other Pathfinders during this reporting period?
Yes
No
By Phone
By E-Mail
In Person
Is there additional information you'd like us to know? (If you would like to include back-up materials with your report, please send them to us via e-mail.)
Also use Part C to describe your participation in at special event.
Yes
No
IMPORTANT! Please note total number of Pathfinder volunteer hours for this reporting period:
Part C - Additional Information/Special Events Report
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