Safe Haven EDUCATIONAL ACTIVITY Report
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1. Safe Haven Educational Activity Reporting Tool

This survey is intended as a way for members of the Safe Haven program committee to report on activities done to educate the public about the program and the law. If you have an activity that you would like to report to the rest of the group, please complete this short survey. The information will be kept in a data base for later retrieval.

1. Today's date

	MM		DD		YYYY
Please enter today's date	Today's date Please enter today's date Month	/	Day	/	Year

*
2. Enter information about yourself.

Enter information about yourself. Name:
Company:
Address:
Address 2:
City/Town:
State:
ZIP:
Country:
Email Address:
Phone Number:

3. Briefly describe your event or activity.

Briefly describe your event or activity.

4. Date of activity/ event

Date of activity/ event

5. Number of attendees and who it was (by individual name or by title, such as school nurses, law enforcement personnel, etc.)

Number of attendees and who it was (by individual name or by title, such as school nurses, law enforcement personnel, etc.)

6. Any materials disributed (fliers, signs, etc.)

Any materials disributed (fliers, signs, etc.)

7. Location of event/activity.

Location of event/activity.

8. Any other relevant information about this event/activity. (What was the response; is any follow-up planned or necessary, etc.)

Any other relevant information about this event/activity. (What was the response; is any follow-up planned or necessary, etc.)

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