Download Community Health Worker Activities Form
FOR INTERNAL USE ONLY (For Strategy 3)
Please complete this form after the manual is taught to record the encounters with the patient.
Participant identification (ID) number:
Name of person completing the form:
Community Health Worker identification (ID) number:
Name of person who taught the manual:
Project Location: Clinic
Which of the following activities do you do? Mark your answer with an X.
Information on this page is taken from the English print version of “Healthy Heart, Healthy Family: A Community Health Worker's Manual.” U.S. Department of Health and Human Services, National Institutes of Health, National Heart Lung and Blood Institute, NIH Publication No. 08-3674, Originally Printed 1999, Revised May 2008.
Last Updated March 2012