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2. 
4. Organization*
   What organization is completing this form?
6. Activity Type
   -- Select One --AdvertisingAlert Sign UpTabling/Booth at EventQuestionnaire Assistance CenterQuestionnaire Action KioskCollateralCanvassingCurriculumEducation ForumEventFlyersMeetingNudge AlertPhone BankingPledge CardsSchool EventSpeaking EngagementTraining DeliveryWebinarOther
7. Describe Event*
   Describe your activity
9. Start Date*
   Start Date
10. End Date*
    End Date
12. Location of the Event*
    Use this format: Address, City, State Zip Code
14. Activity Record
    Link to event pages or recordings, if applicable
16. Communities Reached <50% of Attendees*
    General geographical areas where <50% of attendees live
17. Communities Reach >50% of Attendees*
    General geographical areas where >50% of Attendees live
19. Total # Impressions*
20. % Impressions Considered HTC*
22. Hard to Count Characteristics *

    Select the Hard to Count population in attendance

    1. African American
    2. Area with limited Broadband Subscription Rates/limited internet
    3. Asian American and Pacific Islanders
    4. Children Under 5
    5. Farm Workers
    6. Homeless Individuals and Families
    7. Immigrants and Refugees

    1. Latinos
    2. Lesbian, Gay, Bisexual, Transgender, and Queer
    3. Middle-Eastern North Africans
    4. Other Demographic Population as identified
    5. People with Disabilities
    6. Seniors/Older Adults
    7. Veterans
24. If Other, please list
26. Languages Offered*

    1. English
    2. Spanish
    3. Tagalog
    4. Chinese
    5. Cantonese
    6. Mandarin
    7. Vietnamese
    8. Farsi
    9. Korean

    Check any languages supported at this event
27. Additional Languages
    List any languages not listed in the Languages Offered check list
29. Notes
    Any notes about the event not captured above?
31. How did the event go?
32. What was helpful?
    Was there information or resources that were particularly helpful?
34. What questions came up or what extra support might be needed
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36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

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