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:
Name of news media outlet:
Type of news media outlet
Which CMDHD branch would you like to interview?
Phone number of news media person, including extension:
Email address of news media person:
Topic or reason for call
Is there any other information that will help us get you an accurate, timely response?
When is your deadline?
Do you need someone to interview?
If you need someone to interview, how much time do you estimate is needed for the interview?
5 - 10 minutes
10 - 20 minutes
20 - 30 minutes
If an interview is needed, where can the interview take place?
Over the phone
CMDHD branch office
Do you need any of the following?
Never submit passwords through Google Forms.
This form was created inside of CMDHD.