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Mission Outreach Measures - Quarterly Reporting Form
NOTE: By Policy, at least 80% of overall activity must come from Categories A, B and F
MADD CAS/Affiliate:
Reporting Period: July-Sept Oct-Dec Jan-March April-June
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A. Drunk Driving Prevention and Underage Drinking Prevention
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Tie One On For Safety (Oct. – Dec. report only)
Law Enforcement Activities |
# ribbons distributed: |
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| # sobriety checkpoints assisted |
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| # recognition events: |
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| # officers awarded: |
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| # roll call briefings: |
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| Youth In Action |
Coordinator: |
- Alcohol Purchase Surveys
- Compliance Checks
- Roll Call Briefings
- Shoulder Tap Surveys
U MADD
Court Monitoring
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# stores: |
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% sales: |
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| # stores: |
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% sales: |
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| # briefings: |
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# officers: |
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| # attempts: |
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% purchase: |
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| # sponsored: |
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| # cases: |
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| # felonies: |
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# misd. |
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B. Fundraising
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| Have you worked on: |
| Strides for Change Date: |
sponsor commitments: $ |
| Road Rally Date: |
Current pledges $ |
| MADD Matters Date: |
Current pledges: $ |
| Memorial Gifts Chair name: |
# distribution sites: |
C. Volunteerism and Growth
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| New Members Added: |
# |
| New Active Volunteers Recruited: |
# |
D. Community Outreach
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| Public Speeches (not including Victim Impact Panels): (audience = approximate size) |
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# events:
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audience: |
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# events:
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audience: |
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# events:
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audience: |
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# events:
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audience: |
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# events:
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audience: |
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Exhibits/Information booths and where:
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- Community Events/Health Fairs
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# events: |
audience: |
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# events: |
audience: |
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# events: |
audience: |
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How many media stories has MADD generated?
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- Print (newspaper, magazine, internet, etc.)
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# |
focus: |
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# |
focus: |
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# |
focus: |
E. Policy Activity
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| Lobby Day Coordinator: Date: |
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Policy or Legislation Currently Being Pursued/Tracked:
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| Bill Number
Bill Number:
Bill Number:
Bill Number:
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Focus:
Focus:
Focus:
Focus:
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F. Victim Services
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i. Victim/Survivors Served
NOTE: Answers to the following questions are for this reporting period only.
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New Victim/Survivors Served
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# |
| Victims/Survivors Provided with Ongoing Support |
# |
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Total
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# |
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ii. Victim/Drunk Driving Impact Panels (both adult and juvenile)
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| English |
# |
| Spanish |
# |
| Total number of participants |
# |
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Participant Fee Assessed
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# |
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iii. New Victim/Survivors Demographics
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NOTE: Please report ONLY NEW Victim/Survivor contacts made this quarter below.
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| Race or National Origin |
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Category |
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Number Served |
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*African American |
# |
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*American Indian/Alaskan Native |
# |
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*Asian/Pacific Islander |
# |
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*Caucasian |
# |
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*Hispanic |
# |
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*Other |
# |
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*Unknown |
# |
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TOTAL |
# |
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| Gender |
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Category |
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Number Served |
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*Male |
# |
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*Female |
# |
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*Unknown |
# |
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TOTAL |
# |
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Age (in years)
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Category
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Number Served |
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*0-5 |
# |
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*6-12 |
# |
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*13-17 |
# |
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*18-21 |
# |
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*22-34 |
# |
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*35-64 |
# |
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*65 and over |
# |
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*Unknown |
# |
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TOTAL
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# |
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Victimization
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