Outreach Event Tracking JHU/APL

This form is provided for online submittal of information regarding education & public outreach talks and events pertaining to JHU/APL-managed NASA missions. The JHU/APL Space Department Education & Public Outreach office will submit this information to NASA for official tracking purposes, which is required for each NASA-funded mission. Thank you for taking the time to provide this information.

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NOTE: All information is required (unless "if applicable" is noted beside it).

INFORMATION ON PRESENTER

Name of Presenter:


Prefix	First	Last	Suffix (if applicable)

Presenter Phone Number:

Affiliation: (e.g., JHU/APL, etc.)

Profession of Presenter:

E-Mail Address of Presenter:

INFORMATION ON PRESENTATION/ACTIVITY

Date of Activity: (MM/DD/YY)

Duration of Activity: (Full Day, Half Day, 2 hours, etc.)

Actual Name of Facility Where Activity Occurred:

Address of Facility Where Activity Occurred:

		zip code look up
City	State	Zip Code

Type of Facility Where Activity Occurred:

If other, please enter the type of facility: (if applicable)

Missions Covered: (check all that apply)

CRISM	Geospace/LWS	MESSENGER	NEAR
New Horizons	Solar Probe	STEREO	TIMED
Other

Topic Areas Covered in Presentation: (check all that apply)

Science	Mathematics	Technology	Engineering
Other

Number of People in Audience:

Additional Audience Description (if applicable)

Type of Audience:

If other, please enter the type of audience or indicate N/A:
(Scouts, clubs, Elderhostel, etc.)

If students or teachers, enter the grade level or indicate N/A:

Program Activities: (check one or more)

Lecture	Video	Demonstration	Group Discussion
Audience Q/A	Hand-On	Tour	Other

Mission Materials Distributed: (check one or more) (if applicable)

Fact Sheets	Videos	Posters	Lithographs
CD-ROMs	DVDs		Other

Brief Description/Overview of Talk or Event:

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When form is completed, click Submit!
We will be in contact if we have any questions regarding your submission or if the form is not filled out properly.

Questions?
Please contact Linda Butler via e-mail at linda.butler@jhuapl.edu
or by phone at (443) 778-5746

Site Last Verified: 12/20/2006