Community Health Outreach Program

Address of Event Site

Day(s) of the Week for Event:
MonTuesWedThursFriSatSun

Lead Organization's Name

If for-profit, will this event benefit employees or the public at large?

Please check at least one item
General PublicCollege & UniversitySenior GroupsK-12 StudentsHealth ProfessionalsFaith-basedFamilyCorporate SettingOther

Languages Represented
EnglishSpanishCreoleOther

Age Group of Attendees
0-1819-2425-3536-5051-6970+

Number expected to attend this year *

Please select which one
Miami Dade County Health Department OnlyHealth Dept and Consortium for a Healthier Miami Dade

Please check at least one item
ArthritisAsthmaBlood PressureBreast Cancer InfoBreastfeeding/WICCervical CancerCholesterolDentalDiabetes EducationDomestic ViolenceEnvironmental HealthFamily Planning InfoGlucose TestingHealthy StartHepatitis EducationHepatitis TestingHIV EducationHIV TestingKidCare InfoNutritionProstate CancerSafer Sex MaterialsSexual AssaultSTD EducationSTD TestingSickle CellTB EducationTobacco Cessation

Do you want?(Please check at least one item)
CondomsSafer Sex MaterialsNeither

Site Accommodations for Health Providers (Vendors):
IndoorOutdoorRain ShelterBathroomsPrivate Area for Confidential ScreeningElectricityAV EquipmentRefrigeration (for Vaccines, Test Supplies)

Provide details for vendor parking*

Time for Vendors to Set Up

What Entertainment is Provided?

What Radio and/or TV Spots have been made?

Flyers Distributed to Other Organizations Well in Advance?

Who Will Post Signs in Key Neighborhood Spots?

Any other Marketing Activities?

Comments (Please include special instructions):

DISCLAIMER:
The Florida Department of Health in Miami-Dade County and the Consortium for a Healthier Miami-Dade are NOT endorsing any activity by disseminating this form. The purpose of this form is only to disseminate information about community health fairs and provide a forum for collaboration and partnerships between interested organizations. It is NOT the responsibility of the Consortium to coordinate or determine if there is any sponsorship exclusivity related to each community health fair. Any questions regarding the event must be directed solely to the event planner.
Please leave this field empty.

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HEALTH FAIR REQUEST FORM SURVEY

Target Audience

Requested Services

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