Community Event Entry Form

Part 1 of 2: Event Overview

Health Education Administration (HEA) works to strengthen the Department of Public Health's (DPH) ability to respond to community needs. As a part of this effort, HEA tracks any community event that involves DPH staff.

Please use this entry form to report any community event involving DPH staff. Do not include Speakers' Bureau events (to report a Speakers' Bureau event see https://www.surveymonkey.com/r/sb-speaker-evaluation). To ensure accuracy, we suggest entering your event after it is complete.

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* 1. Your First Name:

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* 2. Your Last Name:

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* 3. Your SPA/Program:

	Program/SPA
Program/SPA:	Program/SPA: Program/SPA menu

Other (only if not listed above)

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* 4. Date of Event:

Event date:

Date

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* 5. Address of Event:

Street Address

City

Zip Code

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* 6. Event Service Areas:

	SPA	District
Based on the event address, select the service planning area and supervisorial district it falls under. You can look this up on http://egis1.lacounty.gov/districtlocator/	Based on the event address, select the service planning area and supervisorial district it falls under. You can look this up on http://egis1.lacounty.gov/districtlocator/ SPA menu	Based on the event address, select the service planning area and supervisorial district it falls under. You can look this up on http://egis1.lacounty.gov/districtlocator/ District menu