Submit Your Activities

This form is for Partners to submit U.S. Antibiotic Awareness Week activities taking place in 2017.

* Required

Organization Name:*

Contact:*

Title:

Address of Event:*

City:* State:*

Zip Code:*

Phone:*

Email Address:*

Organization Web Address:

Twitter Handle:

Facebook:

Instagram:

Name of Activity:*

Activity Date and Time:*

Target Audience: * Select: Community Leaders General Healthcare Providers Media Political Leaders Other

Activity Description: *

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

May we post your city and activity description on the U.S. Antibiotic Awareness Week Website?
Yes No

May we contact you?
Yes No

May we post your contact information with your activity?
Yes No