Houston Department of Health & Human Services H1N1 Community Presentation Requisition Form Survey

Houston Department of Health & Human Services H1N1 Community Presentation Requisition Form

1. Interested in a presentation on H1N1?

1 / 2

50%

If so, it is easy as 1-2-3...

Step 1: Complete the short requisition form with your desired date, time, location and projected audience size.

Step 2: An HDHHS Community Relation Specialist will contact you and confirm logistical requirements on the next business day after your submission.

Step 3: Allow at least a 5-7 day window, so that we can adequately prepare for your training.

1. Contact Information

Contact Information Name
Title
Organization/Company
Work Address
Phone (work)
Phone (cell)
E-mail Address

2. Select your audience type.

Select your audience type. Lay (Non-medical)

Academic (Scientific or Medical Personnel)

3. What is your project audience size?

What is your project audience size? 10-20

21-50

51-99

>100

If greater than 100, enter the project total in the field below:

4. When would you like us to come to you?

	MM		DD		YYYY		HH		MM	AM/PM
Option 1	When would you like us to come to you? Option 1 Month	/	Day	/	Year		Hour	:	Minute	AM or PM
Option 2	Option 2 Month	/	Day	/	Year		Hour	:	Minute	AM or PM

5. Location:

Location: Name:
Address:
City/Town:
State:
ZIP/Postal Code:

6. Please provide any additional information that will assist us in better serving you (i.e. hearing impaired, physical limitations, visually impaired, etc.) 150 characters or less

Please provide any additional information that will assist us in better serving you (i.e. hearing impaired, physical limitations, visually impaired, etc.) 150 characters or less