Facilitator Report for programs that have taken place January 1, 2020 to March 31, 2020 Facilitator InformationPlease provide information about the presenter/facilitator of the program, presentation, training, or health fair. Name* First Last Email* Facilitator's Agency* Program or Event InformationFormat of Presentation*VirtualIn-personHybridProgram Site (Name)* Event Name Event Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State County*AtlanticBergenBurlingtonCamdenCape MayCumberlandEssexGloucesterHudsonHunterdonMercerMiddlesexMonmouthMorrisOceanPassaicSalemSomersetSussexUnionWarrenContact Person* First Last Email (Event Contact)* Event Date* MM slash DD slash YYYY Program Audience* Children Adult Senior Choose all that apply Actual Number of Participants - Adults*Use for programs not in schools only Presenter's Evaluation of ProgramWillingness of group to learn4321Score from 1-4, 4 begin the highest. Program Setting4321Score from 1-4, 4 begin the highest. Participation from group4321Score from 1-4, 4 begin the highest. Program coordinator4321Score from 1-4, 4 begin the highest. Do you feel this program should be contacted for another program in the future? Yes No If yes, when? If no, why?Additional CommentsMaterials Distributed at SitePre-made PacketsEnglishSpanishBothBrochuresBabysitting Do and Do NotGingerbread CoverEnglishSpanishBothAmountEnglishAmountSpanishKeep Your Family Safe from PoisonsBlue coverEnglishSpanishBothAmountEnglishAmountSpanishYour Poison CenterMulti-color circles on coverEnglishSpanishBothAmountEnglishAmountSpanish10 Things Parents Need to Know About Lead ExposureEnglishSpanishBothAmountEnglishAmountSpanishCarbon MonoxideEnglishSpanishBothAmountEnglishAmountSpanishStickers/Magnets/Wallet CardsPoison Help MagnetsEnglish: Red Square 'Poison Help -- Spanish: Dile a una AmigaYesNoPhone StickersWhite sticker sheetFirst ChoiceSecond ChoiceThird ChoicePoison Help Sticker SheetRed stickersFirst ChoiceSecond ChoiceThird ChoiceDouble Sided Wallet CardFirst ChoiceSecond ChoiceThird ChoiceHospital StickersTypically only distributed through websiteFirst ChoiceSecond ChoiceThird ChoicePromotional MaterialsMedicine SpoonsYesNoAmount DistributedOral SyringesYesNoAmount DistributedPoison Help MagnifierYesNoAmount DistributedPencilsYesNoAmount DistributedPensYesNoAmount DistributedPop-SocketYesNoAmount DistributedRed Stress BallYesNoAmount DistributedRed Phone WalletYesNoAmount DistributedChip ClipYesNoAmount DistributedKids Activity BookYesNoAmount DistributedMugYesNoAmount DistributedRetractable ID HolderYesNoAmount DistributedStethoscope TagYesNoAmount DistributedPostersCould You Be Carrying Poison?EnglishSpanishBothNeitherAmount DistributedEnglishAmount DistributedSpanishNJ Poison Control Center ServicesEnglishSpanishBothNeitherAmount DistributedEnglishAmount DistributedSpanishPet PosterEnglishSpanishBothNeitherAmount DistributedEnglishLook-a-LikeEnglishSpanishBothNeitherAmount DistributedEnglishMedication InformationEnglishSpanishBothNeitherAmount DistributedEnglish
