Mobile Mammography Inquiry Survey

Please complete the survey.

1.Contact information(Required.)

Full name:

Phone number:

Email address:

2.Second point of contact(Required.)

Full name:

Phone number:

Email address:

3.General event information(Required.)

Name of event:

Name of organization:

4.Event details:(Required.)

Date of event:

Event time frame:

Event location:

Event confirmation needed by:

5.Type of event ( Check all that apply)(Required.)

Corporate event- Open to all company employees

Community event- Open to the Community and Public

Private-not open to the public

6.Additional details(Required.)

Will your organization require a Memorandum of Understanding (MOU)for this event/partnership?

Will mammograms be paid for by the organization?

Is there a property management company involved with the event location?

Will there be media coverage or elected officials at this event, if so please specify?

7.Are the participants 40 years old or older?(Required.)

Yes

No

Not Sure

8.What type of insurance coverage will participants have for this event? For Corporate partners, please list insurance carrier offered to employees.(Required.)

9.What is the goal for this event?(Required.)

10.Special instructions, requests, or additional comments.(Required.)