Media Report

Please print out this page or download a copy (right click the link and save), and complete.

Contact Name: ______________________________________________________________

Facility Name: ______________________________________________________________

Facility Address: ______________________________________________________________

City, State, ZIP: ______________________________________________________________

Phone Number: ______________________________________________________________

Date of Report: ______________________________________________________________

Please list the results of your local publicity effort. Whenever possible, please attach a copy of the story which ran in the newspaper.

Media Name/Location

Date of Coverage

Type of Coverage

Newspapers:

1. ______________________________________________________________

2. ______________________________________________________________

3. ______________________________________________________________

4. ______________________________________________________________

Radio

1. ______________________________________________________________

2. ______________________________________________________________

3. ______________________________________________________________

Television

1. ______________________________________________________________

2. ______________________________________________________________

Please attach clips, audio or video copies if available.

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