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

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* 1. Organization Name

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* 2. Your Name

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* 3. Email

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* 4. Phone number

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* 5. Which Location would you prefer to Pick-up/Drop-off at?

Jackson County HHS

Josephine County Public Health

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* 6. How many English versions of the paper surveys do you need?

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* 7. How many Spanish versions of the paper surveys do you need?

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* 8. Please check any promotional material you would like included in your survey materials and quantity:

	25	50	75	100	150
Flyer- English	Flyer- English 25	Flyer- English 50	Flyer- English 75	Flyer- English 100	Flyer- English 150
Flyer- Spanish	Flyer- Spanish 25	Flyer- Spanish 50	Flyer- Spanish 75	Flyer- Spanish 100	Flyer- Spanish 150
QR Code Handout- English	QR Code Handout- English 25	QR Code Handout- English 50	QR Code Handout- English 75	QR Code Handout- English 100	QR Code Handout- English 150
QR Code Handout- Spanish	QR Code Handout- Spanish 25	QR Code Handout- Spanish 50	QR Code Handout- Spanish 75	QR Code Handout- Spanish 100	QR Code Handout- Spanish 150
Survey FAQ Sheet- English	Survey FAQ Sheet- English 25	Survey FAQ Sheet- English 50	Survey FAQ Sheet- English 75	Survey FAQ Sheet- English 100	Survey FAQ Sheet- English 150
Survey FAQ Sheet- Spanish	Survey FAQ Sheet- Spanish 25	Survey FAQ Sheet- Spanish 50	Survey FAQ Sheet- Spanish 75	Survey FAQ Sheet- Spanish 100	Survey FAQ Sheet- Spanish 150

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* 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)

2023 CHA Paper Survey Order Form

Question Title

* 1. Organization Name

Question Title

* 2. Your Name

Question Title

* 3. Email

Question Title

* 4. Phone number

Question Title

* 5. Which Location would you prefer to Pick-up/Drop-off at?

Question Title

* 6. How many English versions of the paper surveys do you need?

Question Title

* 7. How many Spanish versions of the paper surveys do you need?

Question Title

* 8. Please check any promotional material you would like included in your survey materials and quantity:

Question Title

* 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)

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* 10. Comments