No Drugs Down the Drain Campaign Agency Participation Survey

1. The statewide campaign steering committee would like to know whether you and your agency plan to participate in the No Drugs Down the Drain campaign. Does your agency plan to participate in the NDDD campaign?

	Yes
	No

2. If you are not planning to participate, please briefly let us know why. Thanks!

3. If yes, who is your NDDD contact for logistics?

First Name

Last Name

Title

Company Name

Street Address

Apt/Suite/Office

City

State

Postal Code

Email Address

Phone Number

URL

4. How do you plan to participate? (You may check more than one answer.)

	Public education in local area
	Provide event or program for disposal of unwanted medication
	Other

5. If you are promoting a disposal option, what type? (You may check more than one answer.)

6. The campaign will promote No Drugs Down the Drain to TV, radio and newspaper outlets throughout the state. If a news outlet would like to do a story in your area, we would like to refer them to a local contact for the story.

Please provide your local media contact who will be available mid-September through mid-October.