· A health promotion program theory or conceptual model is identified and described
· Explanation of how model or theory is applicable to the initiative included
Populating Assessment and Screening
· Screening topic is identified as an A or B preventive screening from the USPSTF.
· Identifies the location with population characteristics numerically: 1) multi-cultural diversity, 2) age and 3) sex.
· Includes rates of risk factors, and aligned with the population in the guidelines
· Includes 2 components of topic- related community statistics, numerically
· Provides an advocacy appraisal that addresses 1) 1) screening 2) related risk factors and 3) multicultural considerations and 4) policy
Screening Venue
· Includes venue, date, time
· Evidence based explanation of appropriateness included
Screening Activity
· Screening activity plan aligns with guidelines
· Aim or objective included
· Measures are aligned with guideline
· Normal and abnormal measures included
· Education description included with three sample motivational questions
· Follow up and referral section included
Cost Table/Statement
· Cost statement overview present.
· Table includes:
· Estimated number of attendees
· Testing instrument costs with source for pricing
· Staff costs
· Rental cost estimate
· Simple supply costs
· Any attendee cost
· Total
Item
Cost Per Item
Number Needed
Total Cost
Supplies
$
$
Staff
$
$
Rentals
$
$
Testing Instruments
$
$
Attendance Fees
$
$
Summary
· Summary includes evidence based content from assessment re: multiculturalism and diversity toward change agent
Conclusion
Reference
Appendix
· Education flyer present with evidence based, patient centered content
References