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2023 CHA Paper Survey Order Form

All paper versions requested are for organizations or community leaders.
If you receive paper surveys you will be responsible to collect names and information for participant raffle entry.

The paper surveys must be ordered, picked up, and dropped off through Jackson or Josephine County Public Health. The information below will be used to set up pick-up and drop-off times.

Please allow 4 days for a response.

To ensure timely data entry, please drop off the surveys within two weeks of them being completed. Our team will enter the paper versions into the survey analysis platform.

If you have any questions please reach out to BagleySP@jacksoncounty.org
1.Organization Name
2.Your Name(Required.)
3.Email(Required.)
4.Phone number
5.Which Location would you prefer to Pick-up/Drop-off at?
6.How many English versions of the paper surveys do you need?(Required.)
7.How many Spanish versions of the paper surveys do you need?(Required.)
8.Please check any promotional material you would like included in your survey materials and quantity:
25
50
75
100
150
Flyer- English
Flyer- Spanish
QR Code Handout- English
QR Code Handout- Spanish
Survey FAQ Sheet- English
Survey FAQ Sheet- Spanish
9.If you need pre-paid postage please indicate below (Please be aware that we are reserving these for communities that need the accommodation and there are a limited amount: Max of 50)
10.Comments