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Request for Health Department Staff Participation in a Scheduled Community Health Fair or Event

Thank you for your interest in Prince George's County Health Department services and programs.

Please note:

All requests received at least 30 calendar days prior to the event start date will be considered after the electronic request form is submitted.
All responses will be based on the availability of staff and resources.
An e-mail confirmation of form submission will be sent to the listed e-mail address after the “Send” button is clicked.
Submission of this request does not guarantee Health Department participation. A staff person will contact you by e-mail to confirm whether the Health Department will participate.
If the Health Department participates, the sponsoring organization must supply tables and chairs as-needed.

All fields marked with * are required.

General Information

Sponsoring Organization Name:*
Event Name:*	Event Contact Person Name:*
Contact Day Phone:* (ex. 000-000-0000)	Contact Cell Phone: (ex. 000-000-0000)
Contact E-Mail Address:*
Event Location/Address:*
City:*	State:*	Zip Code:*

Event Dates and Time

Day 1
Date:*(ex. MM/DD/YYYY)
Event Starts at:* (ex. HH:MM / AM or PM)		AM PM
Event Ends at:* (ex. HH:MM / AM or PM)		AM PM
Day 2
Date:(ex. MM/DD/YYYY)
Event Starts at: (ex. HH:MM / AM or PM)		AM PM
Event Ends at: (ex. HH:MM / AM or PM)		AM PM
In Case of Rain
Date:(ex. MM/DD/YYYY)
Event Starts at: (ex. HH:MM / AM or PM)		AM PM
Event Ends at: (ex. HH:MM / AM or PM)		AM PM

Health Information Materials Request

Addictions and Mental Health	Health Screenings Request
Alcohol Use Prevention/Treatment Bullying Prevention Domestic Violence Prevention Drug Use Prevention/Treatment Mental Health Tobacco Use Prevention/Cessation Underage Drinking/Distracted Driving Other Addictive Substances	Blood Pressure BMI (Body Mass Index) Dental Glucose/Cholesterol HIV Mobile Medical Unit (Must meet certain criteria and when available) Tuberculosis
Adult and Geriatric Health	Maternal and Child Health
Cancer (Breast, Cervical or Colon) Cardiovascular (Heart) Disease Diabetes/HIgh Blood Sugar Nutrition/Eating Healthy Obesity Physical Activity, Exercise and Healthy Lifestyles	Immunizations for Children Health Insurance for Pregnant Women and Children (MCHP) Lead Testing (Environmental and in Children) Prenatal Care WIC Foods for Women, Infants and Children
Environmental Health	Epidemiology and Disease Control
Air Quality Insect/Disease Carriers Food Service Facility Inspections Food Service Manager Training Public Health Emergency Preparedness Public Swimming Pool and Spa Inspection Sexually Transmitted Diseases (STDs) and HIV/AIDS Water and Sewer Inspections	HIV/AIDS Influenza (The Flu) Lyme Disease Rabies Sexually Transmitted Diseases Tuberculosis West Nile Virus
Volunteer Opportunities in Public Health	Speakers Request Topics
College Interns Medical Reserve Corps (MRC) Prince George's County Healthcare Action Coalition Summer Youth Employment Program Tobacco Control Coalition Wellness Ambassador Program	Anti-Drug and Substance Use, Abuse, and Prevention Programs Dine and Learn: How to Cook and Eat Healthy Specialized Re-Entry Services for Males and Females at Adam's House Emergency Preparedness Training for Public Health Emergencies and Disasters
Vaccinations Request	General Public Health Information
Influenza (Flu) Pneumonia Rabies (For cats, dogs and ferrets; Spring season only)	General Health Department Services Available to County Residents Other (Specify):

Additional Information

Audience (who will attend your event; for example, teens or families with children, etc.)	General Public Children Men Teens Women Seniors Handicapped Individuals Veterans
Is the event indoors, outdoors or both?	Indoors Outdoors Both
Number of persons expected to attend event:
Are tables and chairs provided?	Yes No
If the Health Department is unable to participate in your event, would you like to pick up educational materials from the Headquarters Building, 1701 McCormick Drive, Largo MD 20774?	Yes No
Is your organization interested in becoming a:	Flu vaccinations community partner? Community event partner with the Health Department?