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PA Stop & PA Start Media Request Form
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1.
What campaign are you considering for your media messaging?
(Required.)
PA Stop
PA Start
Both
Not Sure
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2.
Contact Information
(Required.)
Your Name
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Agency/Coalition
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Address
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City/Town
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State/Province
ZIP/Postal Code
*
County
*
Email Address
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Phone Number
*
*
3.
Agency/Coalition Description
(Required.)
SCA
Prevention Provider
Communities that Care Coalition
OMPP Coalition
Drug Free Communities Coalition
Overdose Prevention Coalition
Other Prevention Coalition
Recovery Organization/Coalition
Treatment Organization/Coalition
Business
Other Non Profit
Other (please specify)
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4.
What audiences do you want to target with the media materials?
(Required.)
Collegiate Personnel
Community
Faith Based Organizations
Families
LGBTQI Community
Recovery Community
School Personnel (K-12)
Youth
Other (please specify)
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5.
What is the target age range?
(Required.)
17 and younger
18-25
26-64
65 and older
Other (please be specific, e.g. 12-15-year-olds)
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6.
What is your goal for the media campaign?
(Required.)
Increase Collaboration with Faith Based Organizations
Increase Collaboration with other Community Based Organizations
Promote & Market your Programs, Events, or Initiatives
Provide Education
Provide Information about Available Community Resources
Reducing Stigma
Raise Awareness of Prescription Drug Misuse
Other (please specify)
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7.
What type of media materials are you considering?
(Required.)
Outdoor Advertising (i.e. billboards, transit)
Postcards & Direct Mail
Printed Materials
Social Media Content
Tactile Handouts (i.e. brochures, toolkits, posters)
Video and/or Radio PSA's
Web Ads
Other (please specify)
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8.
Do you want customized media materials to include your logo, website, phone number, etc.?
(Required.)
Yes.
No. I prefer something prepared and accessible.
9.
Do you have an approximate date range for your campaign?
Yes
No
I'm flexible
Current Progress,
0 of 13 answered
