Corps Community Month Pre Event Instrument
What is the title of your event (or activity)? * *
2. Description of event (or activity) * *
3. Which best describes your event (or activity)? * *
4. When will your event (or activity) take place? All events should take place during the month of October 2015. (ex: October 10, 2015) * *
5. What time will your event start? (ex: 10:00 am) * *
6. What time will your event end? (ex: 2:30 pm) * *
7. Where will your event (or activity) take place? Address 1: * *
8. Address Line 2 (Suite, Building, Floor etc.):
9. City
10. State
11. Zip
12. Event Planner 1’s Full Name: * *
13. Event Planner 1’s Organization (Include URL if you want it listed): * *
14. Event Planner 1’s Title: * *
15. Event Planner 1’s Work Email: * *
16. Event Planner 1’s Work Phone (ex: 202-555-0000): * *
17. In which categories does Event Planner 1 belong? (Please choose all that apply by holding down Ctrl (PC) or Command (Mac) on your keyboard and clicking multiple selections with your mouse or touchpad.) * *
Academic Institution
Area Health Education Center
Health Department
HRSA Regional Office Staff
Primary Care Office
Primary Care Association
Professional Association
NHSC Alum
NHSC Ambassador
NHSC Provider (Current)
NHSC Scholar (Current)
NHSC Site
Office of Minority Health
State Office of Rural Health
Other
18. Event Planner 2’s Full Name:
19. Event Planner 2’s Organization (Include URL if you want it listed):
20. Event Planner 2’s Title:
21. Event Planner 2’s Work Email:
22. Event Planner 2’s Work Phone:
23. In which categories does Event Planner 2 belong? (Please choose all that apply by holding down Ctrl (PC) or Command (Mac) on your keyboard and clicking multiple selections with your mouse or touchpad.)
Academic Institution
Area Health Education Center
Health Department
HRSA Regional Office Staff
Primary Care Office
Primary Care Association
Professional Association
NHSC Alum
NHSC Ambassador
NHSC Provider (Current)
NHSC Scholar (Current)
NHSC Site
Office of Minority Health
State Office of Rural Health
Other
24. Estimated number of attendees * *
25. Do you anticipate any notable attendees of whom NHSC should be aware (e.g. politicians, political appointees, members of the media, etc.)? * *
26. Did you hold a Corps Community event (or activity) in 2014 or 2015? (Please choose all that apply by holding down Ctrl (PC) or Command (Mac) on your keyboard and clicking multiple selections with your mouse or touchpad.) * *
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Nicole M. Hollis-Walker |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |