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Stay in Circulation Week
Feedback Form

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Tell us what your organization did to help your community Stay in Circulation!  This feedback form is intended to help you gauge the effectiveness of your activities to support the Stay in Circulation:  Take Steps to Learn About P.A.D. campaign, to identify what you think were successful elements of your activities, and to highlight any areas that you think could have been improved (e.g., different kinds of materials needed). 

This feedback form will also enable the P.A.D. Coalition to compile examples of activities and events that can be shared with all Coalition members who may be looking for creative or effective ideas for their community outreach.  The information you provide in this feedback form will also help to inform plans for future campaign efforts, including insight on which materials were most useful, what types of events were most popular, and what tactics worked best. 

On the next page you will find a copy of the form with details on the information that will be of most value to the campaign.  The last page includes a blank form for you to complete.  Please make duplicates of the form as needed.

Please send the form via mail, fax, or e-mail at the conclusion of each event to:
Gwen Twillman
Executive Director
P.A.D. Coalition
c/o 1075 South Yukon Street, Suite 320
Lakewood, CO 80226
Phone:  301-524-1535
Fax:  303-989-0200

Please also include photos of your event when you can.


Organization Name:  ________________________________

Contact: __________________________________________

City, State:  ________________________________________

Event Name
and Date
Location Audience Attendance
Include the name of your event and the date it took place. Include details about the specific venue your event was held—for example, hospital, workplace, or community center. Describe the audience your event was planned for, such as "Hispanic seniors," "general public—all ages," "State public health workers," or "media." If you can provide an estimated attendance, please include it here.
Stay in Circulation Materials Used:
Describe or list the Stay in Circulation campaign materials you used for your event. If possible, please also include the quantities of materials distributed at your event.
Event Description:
You may want to write this section as if you were writing a short piece to include in your Organization's newsletter or member update e-mail.  Highlight the successes and include any notable details:  Did a prominent local official attend?  Did the media cover your event?  If possible, include pictures from your event.
Highlight Areas of Success and/or Areas for Improvement:
Please share any tactics or elements of your event that were particularly successful, or areas that could use improvement (lessons learned).

Download Blank Feedback Form (pdf document icon PDF 56 KB)