Please submit this form at least 72 hours before the event. Event Title * Event Organizer's Name * Event Organizer Contact Information * Event Date * MM DD YYYY Open to Public? * Can CDPH share with other partner agencies, funders, organizations, social media etc. Yes No Start and End Time of Event * Site Attending * Staff Planning to Attend * Would they like to request the Cleveland Department of Public Health Mobile Unit #1 This may or may not be available. The earlier this form is submitted, the better the chances. A staff member will follow-u with you to confirm. Yes No If requesting the Mobile Unite #1, please check off the type of participation they would be interested in the unit providing check all that apply Provide Educational Materials/Resources Table/Booth Blood Pressure Screenings STI (urine based) Screenings Pregnancy Test Family Planning Consultations Immunizations Presentation/Speaker Thank you!
