Please fill out the following form to tell us about completed educational activities. Anything that you report using this form does NOT need to be reported on your annual accomplishment form. Thanks!

* 1. Please provide your first and last name.

* 3. When did this activity occur?

Date of activity

* 4. Approximately how many hours did you spend on this activity?

* 5. What type of activity did you accomplish (check all that apply)?

* 6. How many people were educated?

* 7. Please list email addresses for any contacts from this event. Separate the email addresses with a comma.

* 8. Please use this space to make general comments about this event, such as the group you talked to or the name of the event where you educated well owners.