Pathfinder Partner Organization Activity Report (PPOR)
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.
NOTE: Pathfinder Coordinators should also file an individual Pathfinder Activity Report (PAR) for each reporting period, noting personal outreach activities. Pathfinder Coordinators should complete an additional PAR to report outreach statistics for those who may not be registered Pathfinders, but may have performed outreach activities you're aware of in your city or region.
Please provide the following information for your city or region.
* Denotes Required Field
Part A - Your Information
Report for the Month/Year of:
Part B - Special Events Reporting (training, social event, conference, etc.)
Race/Ethnicity (if known, enter number or percent):
African-American
Caucasian
Name:
E-Mail:
Phone:
Organization Name:
Special Event (Include Name of Event and Date, plus complete Part B):
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
Middle School
High School
Adult 18 - 24
Adult 25 - 34
Adult 35 - 44
Adult 45 - 54
Adult 55 - 64
Adult 65+
Total number in attendance:
Did you provide a birthing hospital, cleft/craniofacial team, ultrasound facility or other medical professional with Pathfinder packets 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
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.)
Yes
No
IMPORTANT! Please don't forget to submit your personal PAR for this reporting period!
Please provide site information/event coordinator information, if applicable.
Name:
Facility:
Address:
City, State, Zip:
Phone:
Describe fully the purpose of the event and related activities.
Part C - Distribution of Materials
DO YOU NEED ADDITIONAL MATERIALS?
Yes
No
Describe the materials you need and in what timeframe.
Is there an upcoming partnership opportunity with your organization or local/regional hospital/team we should be aware of?
Yes
No
If yes, please provide contact information:
Name:
Facility:
Address:
City, State, Zip:
Phone:
Part D - Additional Partnership Opportunities
*
*
*
*
*
IMPORTANT! Please note total number of Pathfinder Partner Organization volunteer hours for this reporting period:
*
