PA Stop & PA Start Media Request Form

Question Title

* 1. What campaign are you considering for your media messaging?

PA Stop

PA Start

Both

Not Sure

Question Title

* 2. Contact Information

Your Name *

Agency/Coalition *

Address *

City/Town *

State/Province

ZIP/Postal Code *

County *

Email Address *

Phone Number *

Question Title

* 3. Agency/Coalition Description

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)

Question Title

* 4. What audiences do you want to target with the media materials?

Collegiate Personnel

Community

Faith Based Organizations

Families

LGBTQI Community

Recovery Community

School Personnel (K-12)

Youth

Other (please specify)

Question Title

* 5. What is the target age range?

17 and younger

18-25

26-64

65 and older

Other (please be specific, e.g. 12-15-year-olds)

Question Title

* 6. What is your goal for the media campaign?

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)

Question Title

* 7. What type of media materials are you considering?

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)

Question Title

* 8. Do you want customized media materials to include your logo, website, phone number, etc.?

Yes.

No. I prefer something prepared and accessible.

Question Title

* 9. Do you have an approximate date range for your campaign?

Yes

I'm flexible