Conceptual Model

· 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

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