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Stroke Smart Michigan Partner Completion Form
Please complete the information below.
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1.
Name
(Required.)
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2.
Email Address
(Required.)
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3.
Phone Number
(Required.)
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4.
Which type of organization are you affiliated with?
(Required.)
Faith-based organization
Skilled nursing facility
Business
Community-based organization (shelter, food pantry, neighborhood associations, etc.)
Pharmacy
Senior center
Elementary school
Middle school
High school
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5.
What is the name and address of the organization?
(Required.)
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6.
Approximately how many people did your organization educate on stroke prevention and preparedness during the community outreach event(s)?
(Required.)
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7.
If applicable, please share a success story or a positive experience from completing the Stroke Smart Michigan Program.
(Required.)
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8.
How can the Stroke Smart Michigan Program and application process be improved?
(Required.)