Mid-Atlantic MWON Accomplishment Report

Please fill out the following form to tell us about completed educational activities. Please allow one week to update your accomplishments after you submit this form. Thanks!

1. First and Last Name

First and Last Name

2. In what state did your educational activity take place?

In what state did your educational activity take place?

3. Please tell us what county the activity took place in?

Please tell us what county the activity took place in?

4. When did this activity occur?

	MM		DD		YYYY
Date of Activity	When did this activity occur? Date of Activity Month	/	Day	/	Year

5. Approximately how many hours did you spend on this activity?

Approximately how many hours did you spend on this activity?

6. What type of activity did you accomplish (check all that apply)?

What type of activity did you accomplish (check all that apply)? Individual consultation

Presentation to a group

Table-top display use

Newspaper or newsletter article

Other (please specify)

7. How many people were educated?

How many people were educated?

8. How many addresses or emails did you collect from those that were educated (please remember to send in your contact sheet or enter the contact information on the reporting web site)?

How many addresses or emails did you collect from those that were educated (please remember to send in your contact sheet or enter the contact information on the reporting web site)?

9. Please use this space to make general comments about this event, such as the group you talked to or the name of the event where you educated well owners.

Please use this space to make general comments about this event, such as the group you talked to or the name of the event where you educated well owners.