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Covering Kids – Survey

Tell
Us About Yourself

Please
fill out the online form below so we can learn
more about you and your efforts to help keep kids
healthy!

Your
feedback helps Covering Kids evaluate its
efforts, plan for new activities and demonstrate
the value of partnering with professional associations.

You
can also
download a survey form in Word format to complete
offline and mail or fax back to us.Address and
contact information is included with this document.

Contact
Name:

Title:

Organization:

Mailing
Address:

 

City:

  State:

  ZIP:
Phone:

Email:

Do
you belong to a professional organization? If
so, which one?

Did
you order any free Covering Kids materials?

Yes

No

How
do you plan to distribute your free Covering
Kids materials?

To
whom do you plan to distribute the free Covering
Kids materials?

Parents

Students

Other (Please describe)

Are
you planning an outreach event?

Yes

No
If so, when?


If so, where?

Are
you working with your state’s SCHIP program
office?

Yes

No


Will you invite media to attend?

Yes

No

Please
describe the event planned:


Do you have any tips on distributing materials
or holding outreach events to add to our tips
for school-based outreach?



Do you have any other comments or suggestions?



To order more free Covering Kids materials and
to learn more about your state program please
log onto www.coveringkids.org.

If
you have questions about the Covering Kids communications
campaign, please call or e-mail (202) 338-7227,
[email protected]

If
you are holding an event, please send us your
response by
Monday, August 26.


You can also e-mail, mail or fax this info to:

[email protected]
or
1010 Wisconsin Avenue, NW Suite 800 Washington,
DC 20007
(202) 338-4480
Fax: 202-822-7775