<p> Report Back Form</p><p>Please use this form to tell us what happened as a result of your appeal</p><p>Date: ______Name: ______Position: ______Dioceses: ______Province: ______City: ______Country: ______Contact number: ______Email: ______</p><p>1. Please fill in the table below with information about the donations you received: </p><p>Donor Date Amount (Name of person, diocese, agency – if known)</p><p>2. How did you use the donations? Please fill in the table below </p><p>What did you do? Please specify Number of Total cost the items/material/resources on items/material/resources items/material/resources which you have spent the donations.</p><p>Total </p><p>3. In addition to providing the items listed above, how else has the church helped the affected communities? </p><p>______</p><p>4. Who has benefited directly or indirectly from your emergency work? Please provide numbers</p><p> o Children ____</p><p> Girls ___</p><p> Boys ___</p><p> o Women_____</p><p> Pregnant women ___  Nursing mothers___</p><p> Widows___</p><p> o Men ____</p><p> o Elderly people ____</p><p> o People with disabilities ___</p><p> o Other____</p><p>5. How has the situation developed, and what is happening now?</p><p>______</p><p>6. Did you liaise with other partner organisations to respond to the emergency? If yes, which ones?</p><p>______</p><p>7. What were the main difficulties that you encountered?</p><p> a) ______</p><p> b) ______</p><p> c) ______</p><p>8. What have been your main achievements? </p><p> d) ______</p><p> e) ______</p><p> f) ______</p><p>9. What lessons have you learned can be used in other emergencies or by other churches?</p><p>______</p><p>10. If possible, please provide some testimonies from members of the community</p><p>2 ______</p><p>11. If possible, please send us some pictures to update the information on the website. </p><p>Thanks for taking the tine to fill in this report back form. We will make sure that there is a report on our website!</p><p>3</p>