Info Community Service Activity Form To record community service associated with WMS and the School of Medicine Your E-Mail Address Subject Comments Through which organization was the community service done? Did your organization perform any community service activities this year? Yes No What is the name of the event? Describe the purpose of the event. In which NC county did the event take place? What was the date of the initial event? Was this a recurrent event? Yes No If this event happened more than once, estimate the number of times it occurred. Which population was this event was designed to serve? For example: general population, the under-served, the un-insured If the event was designed to help a specific group (such as immigrants or the homeless) or individuals with a particular medical issue (such as HIV) please describe: Estimate the total number or people from the community who participated in the event (if this event happend several times, estimate the TOTAL number of individuals served) Estimate the TOTAL hours (even if the event was held several times) of DIRECT SERVICE provided (this excludes driving time and training) Estimate the number of UNC SOM students, by class, who participated in the event. If the event occurred several times, please estimate the TOTAL number of students. MS1: MS2: MS3: MS4: If other UNC students (undergrad or grad) participated in the event, estimate the TOTAL number of students by school including if the event occurred several times. Undergrad: Dentistry: Nursing: Social work: Public Health: Pharmacy: Please list the name(s) of any community agency taht assisted you with putting on this event. Did a faculty advisor help your group with the event? If so, provide the advisor(s) name. Estimate the total cost of putting on the event
