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1. Name (of person filling out this survey) (Required.)

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2. Service or Facility (Please Do NOT use initials) (Required.)

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3. Email address (Required.)

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4. Date of Event (Required.)

Date

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5. City & Location of Event (Required.)

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6. What type of event was this? (Required.)

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7. Who was the intended audience? (i.e. Adult, Geriatric, Pediatric, All) (Required.)

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8. Estimated number of participants: (Required.)

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9. Were TSA-B resources utilized? (Required.)

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10. What TSA-B resources were used? (Required.)

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11. Was TSA-B recognized as a contributor at the event? (only applicable - if you used TSA-B purchased items) (Required.)

T