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

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

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* 3. Email address

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* 4. Date of Event

Date

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* 5. City & Location of Event

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* 6. What type of event was this?

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

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* 8. Estimated number of participants:

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* 9. Were TSA-B resources utilized?

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* 10. What TSA-B resources were used?

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

T