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An activity tracker form for process evaluation and to track inputs and outputs [Question 18 – 1].

Activity Tracker Form

Conduct a process evaluation and track program inputs and outputs by providing this form to staff or volunteers to complete for each activity. You can adapt this form to suit your program’s needs. When collected input responses into a spreadsheet to keep track of program activities. Don’t forget to reflect on the information gathered to see how activities can be improved.

  1. Name:
  2. Date activity took place:
  3. Describe the type of activity implemented (e.g. workshop/brochure development and distribution/Webinar).
  4. Describe the main objectives of the project and the food safety topic addressed.
  5. List all materials and resources used for this activity.
    A. Provide the names of staff or volunteers that worked on this project and # of hours worked.
    Name:                                                          Hours:
    B. List any equipment, printed materials, or tools acquired and used for the activity:
    C. Other resources used:
    D. Cost breakdown:
    $         for
    $         for
    $         for
    $         for
    $         TOTAL
  6. How was the activity advertised (include duration of promotion and where it was advertised)?
  7. What was the target participation goal for this activity? ____________
    How many individuals actually participated in the activity? ____________
  8. How many educational handouts or materials were distributed?
  9. How many participants filled out the sign in sheet and checked that they would like to continue to receive follow up information? ______________
  10. How many evaluation forms were filled out and collected?
  11. Based on the evaluation form what was the average overall rating of the activity?
  12. Describe participant reactions to the activity and information shared.
  13. Do you think the activity was implemented or planned or intended? Why or why not?
  14. Do you feel the program has enough resources to provide people with the food safety information they need?
  15. What challenges did you face with planning and implementing the activity?
  16. What were the strengths of the activity? Please provide specifics about what worked well in the planning and implementation of the activity.
  17. Do you think any aspect of this activity could be improved? How?
  18. If available, please provide demographic information on participants or contacts.
Direct Contact Method: Circle All That Apply Gender Counts Ethnicity Counts Adult/Youth Counts


Group discussion One on one interaction

Other (specify)






Native Hawaiian or other Pacific Islander:

American Indian or Alaska Native:

Hispanic or Latino:


Youth 5-11 years:

Youth 12-18 years:

Adults 19-64 years:

Older Adults 65+ years:


Indirect Contact Method: Circle All That Apply Explain how you arrived at count of indirect contacts:
Social Media


Public Service Announcements



Other (specify)


Activity Tracker Form – Docx


Activity Tracker Form – PDF


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