Spike 2010 Reporting Form

1. Spike Reporting Form

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* 1. Name

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* 2. Email address

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* 3. School/Organization

Other (please specify)

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* 4. City/Town

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* 5. State

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* 6. Number of participating students

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* 7. Grade/Level (Check all that apply.)

Pre-K

Other (please specify)

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* 8. How much time did you time did you spend on poison prevention?

30 minutes or less

Between 30 minutes and an hour

More than an hour

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* 9. What activities/materials did you use? (Check all that apply.)

Video

Sing Along With Spike (Teacher's Guide Activity)

Experience Chart (Teacher's Guide Activity, available on our website)

Can Good Things Be Bad for You? (Teacher's Guide Activity)

Student take-home packets

Candy or Medicine? Poster

Maze activity page

Connect-the-dots activity page

Word search activity page

Do-it-yourself hand puppets

Press release (available on website)

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* 1. Name

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* 2. Email address

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* 3. School/Organization

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* 4. City/Town

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* 5. State

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* 6. Number of participating students

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* 7. Grade/Level (Check all that apply.)

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* 8. How much time did you time did you spend on poison prevention?

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* 9. What activities/materials did you use? (Check all that apply.)

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* 10. Please share any comments on the program or ideas for improving it.