IDDAW Activity Tracking for Health Care Provider
This form is for Health Care Providers. Once the campaign is completed, please compile data for your hospital/medical organization and report your cumulative results within this activity tracking form.
Email address *
What is the name of your organization? (please spell it out) *
Your answer
What is the street address, city, state and zip of your organization? *
Your answer
In what county is your organization located? *
Your answer
How many residents do you serve? *
Your answer
Please enter the estimated total number of minutes dedicated to the topic of distracted driving. (please enter minutes, not hours) *
Your answer
How many posters and signs have been placed around your organization? *
Your answer
How many community announcements have been made by your organization? *
Your answer
If you sent emails to community members, how many were reached? *
Your answer
If you sent emails to staff members, how many were reached? *
Your answer
If you mailed information to community members, how many were reached? *
Your answer
If you mailed information to staff members, how many were reached? *
Your answer
How many flyers were distributed at events and/or your location? *
Your answer
How many banners were displayed at your location? *
Your answer
Is information regarding distracted driving on your webpage? *
Was the event covered by your local newspaper? *
Was the event covered by your local radio station? *
Was the event covered by your local television station? *
How many people took a pledge against distracted driving? *
Your answer
A copy of your responses will be emailed to the address you provided.
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