Injury Prevention Program

The following questions will allow us to identify contacts for injury prevention activities and programs in your area.

First Name: 
Last Name: 

Organization: 
Address: 
Phone: 
Email: 
Website: 

Which Florida counties do you work in?
Statewide
Multiple Counties (specify):
Single County (specify):

Would you like to receive occasional injury prevention updates (legislation, best-practices, training opportunities) from the IPP?
Yes
No

May the IPP provide your contact information and injury prevention focus in the Statewide Injury Prevention Resources List?
Note: If at any time you wish to be removed from the Resources List, please contact the IPP at the address listed at the bottom of this page.
Yes
No

The following questions pertain to the type of injury prevention activities that your organization or agency participated in during the last calendar year.

Please select the type of injury prevention activities that your organization or agency particpated in. (Please select all applicable.)
Bicycle Safety
Child Passenger Safety
Drowning Prevention
Fall Prevention
Fire Safety / Burn Prevention
Motor Vehicle Safety
Motorcycle Safety
Occupational Safety
Pedestrian Safety
Poisoning Prevention
Suicide Prevention
Violence Prevention
Other (specify):

What types of injury prevention activities is your organization or agency doing? (Please select all applicable.)
Community Events
Educational Campaigns
Printed Materials
Public Service Announcements (Radio or Television)
Other (specify):

Please indicate any additional training that may be of benefit to you or your organization or agency. (Please select all applicable.)
General Injury Prevention
Bicycle Safet
Child Passenger Safety
Drowning Prevention
Fall Prevention
Fire Safety / Burn Prevention
Marketing Injury Prevention
Motor Vehicle Safety
Motorcycle Safety
Occupational Safety
Pedestrian Safety
Poisoning Prevention
Suicide Prevention
Violence Prevention
Other (specify):