Flu AFM Opioids Health Fair & Presentation Request Form Thank you for your interest in receiving information from Cook County Department of Public Health. To request CCDPH staff participation or materials at a health fair or a presentation. Health Fairs and Presentation Requests Organization/Agency Name*Contact Person (First Name)*Contact Person (Last Name)*Phone Number*What is the best number to reach you?FaxEmail*Mailing AddressStreet AddressCityStateAKALAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMAMEMDMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYZipEvent DescriptionEvent Name*Event Date (MM/DD/YY)*Event Time (e.g. 12:00 PM to 2:00 PM)Event LocationBuilding Name (If applicable)Street AddressCityStateAKALAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMAMEMDMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYZipThis event will be held (select one):InsideOutsideHas CCDPH participated in this event before?*YesNoHow many years has this event taken place?Target Population - Check all that apply. Older Adults (65 years and older) Adults Families Caucasian African American Latino Other Anticipated Number of Participants50-100100-150150-200200-300300-500500 and abovePlease include day-of-event details, such as set-up time, driving/parking directions, and contact information (e.g. cell phone number).Additional DetailsHealth Information Requested - Check all that apply. Breast and Cervical Cancer Screening Education CCDPH Clinic Sites and Contact Information Chronic Disease Self-Management Emergency Preparedness Family Genetic Education - provided by a public health nurse Flu Prevention (Seasonal Flu, Pandemic Flu) Healthy Lifestyle (Healthy Eating/Physical Activity) Heart Disease Immunization Schedule Lead Poisoning Prevention Sexual Health Tobacco Prevention and Smoking Cessation Violence Prevention (Bullying, Domestic Violence) West Nile Virus CAPTCHA More About UsAbout CCDPH Advisory Council Annual Reports CCDPH Fact Sheet Jobs Laws & Rules Media Archive Permits and Licenses Strategic Plan Suburbs Served Success Stories WePlan 2020 Related InformationCook County Government Cook County Health Northern Illinois Public Health Consortium Public Health Accreditation Board Illinois Department of Public Health Centers for Disease Control
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