Clinical Program Outreach Recap

Event Lead (Full Name):*
Program services used for this event:*
Organization Information
Name of Organization*
Organization's Website
Please select services performed for this organization (check all that apply):*
- Gym/Cheer Biomechanical Screens
- Warm-Up Instruction
- Gym/Cheer-specific conditioning programs
- On-site competition or practice coverage
Please select services performed for this organization (check all that apply):*
- Injury Prevention Workshops
- Developing appropriate training progressions
- Cross country/track team screens
Please select services performed for this organization (check all that apply):*
- Planning services – Concussion Protocol
- ImPACT Testing (baseline and post-concussive)
- SCAT5 Testing
- Return to Participation + Return to Learn Consultation
Please select services performed for this organization (check all that apply):*
- Risk Assessment Screens
- Sport-Specific Dynamic Warm-Up Instruction
- Movement Workshop
Please select services performed for this organization (check all that apply):
- Overhead Athlete Biomechanical Screen
- Video Throwing Analysis
- Fault Correction Strategies/Drills
- Swim Screen
Please select services performed for this organization (check all that apply):*
- Functional Movement Screens
Please select services performed for this organization (check all that apply):*
- Pointe Readiness Screens
Please select services performed for this organization (check all that apply):*
- Relative Energy Deficiency in Sports (RED-S) written screens
- Pelvic Health written screens
- Lectures on RED-S and pelvic health
Please select services performed for this organization (check all that apply):*
- Lectures on opioid addiction
Screening Event Information
Date of screening event*
MM slash DD slash YYYY
Location of screening event*
Street Address Address Line 2 City State ZIP Code
Number of participants:*
Number of staff utilized:*
PT
PTA*
PTA
ATC*
ATC
If GAP was requested, estimate cost at $50 per staff member:
# of Staff @ $50 per = Total
Was there a sponsorship cost to be onsite to offer the screens:*
- Yes
- No
Sponsorship cost:*
Deliverables provided for event (select all that apply):*
- ACL Risk Assessment Report Card to athlete
- Summary of findings to coach for all athletes
- Post-screen meeting with athlete in clinic
- Instruction in sport-specific dynamic warm-up program with handouts
- Tiered HEP
- Weekly supervised progressive prevention program
- Lecture
- Other: please specify
Deliverables provided for event (select all that apply):*
- VGA Report Card to Runner
- VGA Booklet
- Bike Fit Report Card to Cyclist
- Summary of Findings to Coach or Physician
- Post-screen phone call or meeting with client
- Summary of finding to coach for all athletes
- Post-screen meeting with athlete
- Fault correction strategies/drills
- HEP
- Lecture
- Other: please specify
Deliverables provided for event (select all that apply):*
- HEP
- ACL Risk Assessment Report Card to athlete
- Summary of findings to coach for all athletes
- Cheerleading or gymnastics dynamic warm-up
- Cheerleading or gymnastics conditioning program
- Instruction in sport-specific dynamic warm-up program with handouts
- Post-screen meeting with athlete in clinic
- Lecture handouts
- Other: please specify
Deliverables provided for event (select all that apply):*
- Corrective exercises
- Summary of finding to coach for all athletes
- Post-screen meeting with athlete
- Fault correction strategies/drills
- HEP
- Lecture
- Other: please specify
Deliverables provided for event (select all that apply):*
- VTA report card
- Summary of findings to coach or physician
- Summary of findings to coach for all athletes
- Post-screen phone call or meeting with clients
- Fault correction strategies/drills
- HEP
- Lecture
- Other: please specify
Deliverables provided for event (select all that apply):*
- Sports Edge Tennis Reports Card to Athletes
- Summary of findings to coach for all athletes
- Post screen meeting with athlete in clinic
- Athlete or team specific handouts on injury prevention
- Lecture
- Other (please specify):
Deliverables provided for event (select all that apply):*
- Corrective balance exercises
- Summary of findings to parent for athlete
- HEP
- Lecture
- Other: please specify
Other:
Was a physician present for event:*
- Yes
- No
Please fill in physician name:*
Physician Name
How many potential patients were made as a result of this event already:*
What is the potential future opportunity? Please estimate the number of potential patients:*
Successes related to this event (list 2-3):
Challenges related to this event (list 2-3):
Were estimated costs accurate? Did we spend more/less on staffing costs and marketing collateral than we anticipated upon request?*
Name
This field is for validation purposes and should be left unchanged.

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Clinical Program Outreach Recap

Clinical Program Outreach Recap Form

Organization Information

Screening Event Information

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