Stamp Out Smoking News

Name of Organization

Contact Person

Address

Contact Number(s)

Email Address

Organization Affiliation(s)(check all that apply):

 TPCP Funded<br /> MISRGO Funded<br /> ADH Unit<br/> Coalition<br /> CHPS<br /> CHNS<br/> CSH<br /> Employee Wellness<br />

Other State Agency (what agency)

Other (please explain)

Name of Event

Event Date and Location

County(ies) serviced by event:

Target Population(s) of Event

Estimated Number of Individuals Served

Number of Individuals Served in Previous Years

Will event be advertised (if yes when and where)?

Will advertisement(s) mention SOS? (if yes provide specifics)?

Will there be media coverage of event (if yes provide specifics)?

TPCP goal area(s) to be positively impacted by event (mark all that apply and explain how):

Prevent the initiation of tobacco use among youth

Promote cessation

Eliminate exposure to secondhand smoke

Identify and eliminate disparities related to tobacco use among different populations

Collateral Items Request (list items and quantities)