Complete the form entirely within 14 days of the program/project or event. Print a completed copy of the form and retain in Chapter files.

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* 1. Chapter Name:

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* 2. Region:

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* 3. Name of Program:

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* 4. Program Requested by:

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* 5. Date of Service

Date 

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* 6. Location of Event:

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* 7. Number of Sorors/Fraters Participating

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* 8. Zip Code of Service Site

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* 9. Event Service Catergory

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* 10. If you answered Disease Prevention and Health Promotion in the above question, what National Program ?

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* 11. Was the event: 
(Choose all that apply)

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* 12. Please briefly describe Education/Screening topic, if not listed above

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* 13. Participants age range:
(Choose all that apply)

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* 14. Level Of Involvement:
(Choose all that apply)

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* 15. Population Served: 
Select all that apply.

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* 16. What is population education level? Select all that apply.

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* 17. Number of Participants reached:

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* 18. Number of participants referred:

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* 19. Referrals made to:

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* 20. Number of Participants follow-up

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* 21. Follow-up made to:

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* 22. Email Address:

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* 23. Antibasileus (Programs and Projects Chairperson):

T