112812_MAPHTC: SIGN-IN SHEET- Grand Rounds
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1. Sign-in Sheet
. First & Last Name or Organization Name
First & Last Name or Organization Name
. Did you watch this webcast with other people?
Did you watch this webcast with other people?
How many people were watching in your group NOT including yourself (please have only one person in your group report this number, so that your group isn’t counted more than once)
. In which of the following disciplines do you practice? (Please check only ONE)
In which of the following disciplines do you practice? (Please check only ONE)
Communtiy Health Worker
Mental Health & Substance Abuse
Public Health Law
Public Helath Policy
. In what type of organization do you work?
In what type of organization do you work?
City Health Department
County Health Department
Tribal Health Department
Public Health Community Based Organization
State Health Department
If County Health Department, please specify which County. If State Health Department, please specify which State.
. What is your gender and age?
What is your gender and age?
Male- Under 20
Male- 60 or older
Female- under 20
Female- 60 or older
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