New Jersey Poison Information & Education System

Before placing your order please take a moment to complete this survey. You will be directed to the program request page once you have completed the information below. Your participation will assist us in providing quality services to communities across the state. Please check your response for each question.

Demographic Information

Your Age

Race

Gender

Male Female

Is English your first language?

Yes No If no please list language:

County

Profession

If Other please specify:

Type of Organization / Association

If Other please specify:

Have you attended a Poison Prevention presentation within the last year?

Yes No

Have you ordered poison prevention educational materials within the last year?

Yes No

Have you called the Poison Center Hotline (1-800-222-1222) within the last year?

Yes No

Are you aware of the following Poison Center services?

a.	Public Outreach Services – Poison Prevention Presentations	Yes No
b.	Poison Prevention Education Materials	Yes No
c.	Professional Education	Yes No
d.	Poison Emergency Assistance/Information	Yes No
e.	Information on Poison Safety	Yes No

Have you EVER contacted the Poison Center to utilize any of the following services?

Poison Center Services			If yes please check a contact method
a.	Public Outreach Services – Poison Prevention Presentations	Yes No	Hotline	Website
			Email	Staff Contact

b.	Poison Prevention Education Materials	Yes No	Hotline	Website
			Email	Staff Contact

c.	Professional Education	Yes No	Hotline	Website
			Email	Staff Contact

d.	Poison Emergency Assistance/Information	Yes No	Hotline	Website
			Email	Staff Contact

e.	Information on Poison Safety	Yes No	Hotline	Website
			Email	Staff Contact

Would you contact the Poison Center in the FUTURE to utilize the following services?

Poison Center Services			If yes please check a contact method
a.	Public Outreach Services – Poison Prevention Presentations	Yes No	Hotline	Website
			Email	Staff Contact

b.	Poison Prevention Education Materials	Yes No	Hotline	Website
			Email	Staff Contact

c.	Professional Education	Yes No	Hotline	Website
			Email	Staff Contact

d.	Poison Emergency Assistance/Information	Yes No	Hotline	Website
			Email	Staff Contact

e.	Information on Poison Safety	Yes No	Hotline	Website
			Email	Staff Contact