Program Report Form Program Report Form Instructor InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Email* Program/Event InformationEvent*Sponsoring Organization(s)Date of Event MM slash DD slash YYYY Location of Event* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Length of Event*Number of People ReachedNumber of People Attended*Age Range of Audience*Number of Materials DistributedNumber of Stickers Distributed*Number of Magnets Distributed*Number of Self-printed Brochures Distributed*Preventing Poisons in the HomePoisonous PlantsBites, Stings and Other ThingsMedicine SafetyNumber of Self-printed Brochures Distributed*Food PoisoningPets and PoisonsRabies and Animal SafetyCarbon MonoxideNumber of Self-printed Brochures Distributed*Pesticide SafetyThe Oregon Poison CenterSynthetic DrugsOther Material(s) DistributedCommentsComments
