Houston Department of Health & Human Services H1N1 Community Presentation Requisition Form

1. Interested in a presentation on H1N1?

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50% of survey complete.

If so, it is easy as 1-2-3...

Step 1: Complete the short requisition form with your desired date, time, location and projected audience size.

Step 2: An HDHHS Community Relation Specialist will contact you and confirm logistical requirements on the next business day after your submission.

Step 3: Allow at least a 5-7 day window, so that we can adequately prepare for your training.

Question Title

* 1. Contact Information

Name

Title

Organization/Company

Work Address

Phone (work)

Phone (cell)

E-mail Address

Question Title

* 2. Select your audience type.

Lay (Non-medical)

Academic (Scientific or Medical Personnel)

Question Title

* 3. What is your project audience size?

10-20

21-50

51-99

>100

If greater than 100, enter the project total in the field below:

Question Title

* 4. When would you like us to come to you?

Option 1

Date

Time

AM/PM

Option 2

Date

Time

AM/PM

Question Title

* 5. Location:

Name:

Address:

City/Town:

State:

ZIP/Postal Code:

Question Title

* 6. Please provide any additional information that will assist us in better serving you (i.e. hearing impaired, physical limitations, visually impaired, etc.) 150 characters or less