Program Report Form – Minnesota Regional Poison Center

Name(Required)

First Last

Please Choose Your State(Required)

Address

Street Address Address Line 2 City ZIP / Postal Code

Phone(Required)

Email(Required)

Event(Required)

Sponsoring Organization(s)

Date of Event

Length of Event(Required)

Location of Event(Required)

Street Address Address Line 2 City State ZIP Code

Number of People Attended(Required)

Age Range of Audience(Required)

Number of Stickers Distributed(Required)

Number of Magnets Distributed(Required)

Number of Brochures Distributed(Required)

Number of Self-printed Brochures Distributed(Required)

Bites, Stings, and Other Things

Carbon Monoxide

Food Poisoning

Medicine Safety

Number of Self-printed Brochures Distributed (continued)(Required)

Pesticide Safety

Poisonous Plants

Preventing Poisons in the Home

Synthetic Drugs

Other Material(s) Distributed