Reporting Date (Today's Date):
1. Organization and Event Details: *
2. Location of Event: *
3. Type of Event (check all that apply):
Media Event or Campaign
Workshop / Training
Policy Decision Making / Implementation
Information Gathering / Survey
Conference / Meeting
Educational Materials / Website
Air Quality Flag Program
Coaches' Clipboard Program
Home Assessments - If checked, how many have you conducted?
Health Fair Display
- If checked, how many have you conducted?
School Assessments - If checked, how many have you conducted?
(Enter up to 50 characters.)
4. Provide a brief description of the event, including its purpose, in the space below. Limit the description to 250 characters. *
5. Target Audiences (check all that apply): *
6. Number of people impacted by this event, or estimated number in attendance: *
(Enter number up to 4 digits.)
8. Are you willing to be contacted as a reference for other organizations interested in conducting projects like yours? If so, please list contact phone number, mailing address, and email address.
9. Additional Comments - If you have any additional comments, please enter them below. You may enter up to 500 characters.
10. Would you like to be included in the AANC listserv for statewide asthma-related announcements and updates? If so, please provide your email address (even if you provided it in question 10).
11. If you have examples of materials used during the event/project, feel free to attach them electronically via email. Hard copies of materials can be sent to the following address or fax number:
AANC Environmental Committee
c/o N. C. Asthma Program
1915 Mail Service Center
5505 Six Forks Road
Raleigh, NC 27699-1915
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