Contact Information Form

Attachment 9: Contact Information Form

[Name of Event]

[Date of Event]

[Location of Event]

Because this meeting is federally funded, we have been asked to collect the following information from each participant. All information provided will remain confidential. Please print responses clearly.

Name: _______________________________

Agency Name and Address: _________________________________________

City: __________________________ State: __________ Zip: ____________

Work Phone: ________________ E-mail address: _______________________

Are you willing to be contacted for a brief, Yes

one-month follow-up evaluation of this event? No

If yes, what is your preferred method of contact? E-mail

Mail