First Name:

Last Name:

Title:

Organization:

Address:

City:

State: Kansas

Zip:

Daytime Phone:

Email Address:

Number of employees (including owner):
0-5    6-10    11-20    21-50    51+

Nature of organization (i.e. police, fire, EMS):

Are there any specific issues you would like us to address in future safety materials?

How do you plan to use these safety materials? (Check all that apply)
Safety meeting    
New recruit training    

Other (explain)

How likely is your organization to use each of the following safety materials?

	Would Use	Might Use	Wouldn't Use
Booklet
Slide show
Poster
Trainer's guide
Website