Flu Season Event: Submit Your Plans

Organization Name: (required)

Contact: (required)

Title:

Address: (required)

City, State, Zip: (required)

Phone: (required)

Fax:

E-mail: (required)

Web Address:

Name of Activity: (required)

Activity Date and Time: (required)
  7:00 AM8:00 AM9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM6:00 PM7:00 PM8:00 PM9:00 PM10:00 PM 

Target Audience: (required)
OtherGeneralHigh RiskHealth Care ProvidersMediaCommunity LeadersPolitical Leaders

Type of Activity: (required)
Immunization ClinicExtended Immunization Hours/DaysNews ConferenceHealth FairCoalition MeetingTelevision Program/InterviewRadio Program/InterviewProfessional TrainingPublic Education Communication CampaignFaith CommunityMedia-OtherOther

Activity Description: (required)

Community Partner Listing:

Evaluation and/or Follow-up Plans: (required)
Include any information you plan to obtain and report such as: number of vaccinations, number that attended and/or received materials, website metrics where applicable, information requests that were difficult to meet, lessons learned, etc.

May we post your city and activity description on the CDC Seasonal Influenza (flu) Website?
Yes
No

May we contact you?
Yes
No

 OR