Error messages displayed when you click on the "Submit" button show a Question number.

The question number indicated in this error message does not correspond

with the question number listed on the Web page.

The following list identifies what entry the error refers to:

Incomplete         Survey Field

Form Ref

Question 1:            Date: (mm/dd/yy):

Question 2:            Name:

Question 3:            Job Title:

Question 4:            Organization:

Question 5:            Phone (###) ###-####:

Question 6:            Email:

Question 7:            Enter county where organization headquarters is located:

Question 8:            Identify Your Organization Type: (Select one only)

Question 9:            If you selected City: Select City/Town from drop dow

Question 10:          If you selected Federally Recognized Tribe : Select a

Question 11:          If you selected Hospital: Select appropriate Hospital

Question 12:          If you selected Local Health Jurisdiction: Select LHJ

Question 13:          If you selected School District: Select appropriate D

Question 14:          If you selected State Agency: Select Agency from drop

Question 15:          Identify the Discipline(s) your organization is reporting fo

Question 16:         1: Has an executive order, directive, policy, procla

Question 17:         2: If your Agency, Organization or Department (AOD)

Question 18:         3: If your Agency, Organization or Department (AOD)

Question 19:         4: If your Agency, Organization or Department (AOD)

Question 20:         5: If your Agency, Organization or Department (AOD)

Question 21:         6: If your Agency, Organization or Department (AOD)

Question 22:         7: Has your Agency, Organization or Department (AOD)

Question 23:         8: If your Agency, Organization or Department (AOD)

Question 24:         9: Indicate the number of personnel within your Agency

Question 25:         10: Indicate the number of personnel within your Age

Question 26:         11: Indicate the number of personnel within your Age

Question 27:         12: Indicate the number of personnel within your Age

Question 28:         13: Has your Agency, Organization or Department (AOD

Question 29:         14: Does your Agency, Organization or Department (AO

Question 30:         15: Does your Agency, Organization or Department (AO

Question 31:         16: If your Agency, Organization or Department (AOD)

Question 32:         17: If your Agency, Organization or Department (AOD)

Question 33:         18: If your Agency, Organization

Question 34:         I certify that all information contained in this report is a

Question 35:         Comments regarding the submission of reports using this