ACTIVITY REPORT FORM

Presenter Name   

Address 

City      State      Zip  

Phone      Fax        Email   

Date of Activity      Approximate audience number?  

Group or Organization Name  

Please check the box that best describes the activity/group you worked with:

News Media Organization	Youth Education & Information Organization	Civic Organization
Food/Health Organization	Beef/Agricultural Industry Organization	Other

 Activity done in urban area of (city) population  (number)

Did the activity receive any additional publicity other than at presentation time (ex:  newspaper/magazine/newsletter articles, radio or television coverage/interviews)? 

Yes No

If yes, please provide circulation numbers for print media coverage and/or estimated audience reach of electronic media coverage.

Publication/Station Name	Media Type (i.e. newspaper, radio, magazine, etc.)	Circulation or Audience Size
ex:                                           KVTV	Television	25,000 Homes

Please describe additional media coverage below and attach copies if possible. 

For example:  I was interviewed on the KVTV cooking show, Cooking with Kate.  I explained about the role of beef in a healthy diet.