Preparedness Presentation Request Form
Accessibility Notice / Aviso de Accesibilidad
If you need assistance or an alternative format to complete this form, please email ncleverly@swuhealth.gov.
Si necesita asistencia o un formato alternativo para completar este formulario, por favor envíe un correo electrónico a: ncleverly@swuhealth.gov.

Purpose: This request form is for a basic emergency preparedness presentation intended for community groups to help them prepare for themselves and their families. The presentation takes 30-40 minutes but can be shortened or extended depending on group needs. There is no cost for the presentation.
Audience: Community groups.
Estimated Time To Complete Form: 5 minutes.
Instructions: Provide details below.

Notice for non-public personal data collection available at: swuhealth.gov/public.
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Your Name *
Enter the first and last name of the point of contact.
Phone Number *
Enter the phone number of the point of contact.
Email
Enter the email of the point of contact.
Group/Organization *
Enter the name of the group/organization that the presentation is intended for.
Preferred Date of Presentation
Enter the preferred date for the presentation by using the calendar icon. The format is month, day, year.
MM
/
DD
/
YYYY
Additional Comments
Please put any additional comments here.
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