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
