|
#3 2006 Back
Up your Birth Control Evaluation Form
Name ________________________________________________________________
Address_______________________________________________________________
Organization____________________________________________________________
Phone_____________________________Email_______________________________
Date(s) of you Back Up your Birth Control Activities _____________________________
How will the Back Up Your Birth Control Campaign fit into
your organizational goals for 2006?
Do you undertake Back Up Your Birth Control
Related activities only on the Day of Activism (please specify duration
and time period) or at other times?
Please describe any other activities that
you undertook or that you would like to undertake that are not currently
promoted by the Back Up Your Birth Control Campaign.
Did you visit Wal-Mart to verify that they
stock EC? Did you find the survey tool helpful?
Which of the sample documents or materials
did you find the most helpful?
Which documents or suggested activities in
the Toolkit did you find needed improvement? Why?
Did you use the Back Up Your Birth Control
website as a resource?
| Back Up Your Birth Control Activity |
Type of Materials |
Goals |
| Local Media Activities: |
|
# Media Hits (articles, radio, interviews,
etc) |
| |
|
|
| |
|
|
| |
|
|
| Public Awareness Activities: |
|
# People Attending Event or Receiving Materials |
| |
|
|
| |
|
|
| |
|
|
| Campus Activities: |
|
# People Attending Event or Receiving Materials |
| |
|
|
| |
|
|
| |
|
|
| Legislative Activities: |
|
# of Legislators Contacted |
| |
|
|
| |
|
|
| |
|
|
| Engaging the Medical Community: |
|
# People Attending Event or Receiving Materials |
| |
|
|
Feel free to use additional sheets
with evaluation form if necessary.
Please return to the Back Up your Birth Control Campaign
by April 21st, 2006
427 Broadway, 3rd Floor, NY, NY 10013,
(P) 212-343-0114 x25, (F) 212-343-0119, info@buybc.org
|
