CMDHD Media Interview Request Form
Media Partners: Central Michigan District Health Department will continue to provide over the
phone, in person and on camera interviews upon request and with advance notice whenever
possible. If you wish to conduct an interview or obtain health information for a news story, please
fill out and submit this form. Upon receiving this form, health department personnel will identify an
appropriate spokesperson to fulfill your request. Thank you for your interest in public health issues.
Name of reporter, producer or editor: *
Your answer
Name of news media outlet: *
Your answer
Type of news media outlet *
Which CMDHD branch would you like to interview? *
Phone number of news media person, including extension: *
Your answer
Email address of news media person:
Your answer
Topic or reason for call *
Your answer
Is there any other information that will help us get you an accurate, timely response?
Your answer
When is your deadline? *
Your answer
Do you need someone to interview? *
If you need someone to interview, how much time do you estimate is needed for the interview?
If an interview is needed, where can the interview take place?
Do you need any of the following?
Never submit passwords through Google Forms.
This form was created inside of CMDHD. Report Abuse