IDPH Event/Outreach Request Form

In the event of an emergency after hours and on the weekend, contact:

800-782-7860 (Illinois Only)
217-782-7860 (Out of state)

535 W. Jefferson St.
Springfield, IL 62761
217-782-4977

122 S. Michigan Ave.
Chicago, IL 60603
312-814-2793

Questions or Comments

Contact Information
Host Organization/Legislator (required):
Contact Person (required):
Phone (required):
Fax:
Cell:
E-mail (required):
Event Information
Name of Event (required):
Date (required):
Start Time (required):
Timeframe:
Location (required):
Address (required):
Expected Attendance Number:
Type of Audience:
Cost:
Will media be present? If yes, who?:
Type of Participation
Booth Presentation Health Screenings Speaking Engagement (Director/Assistant Director)
Area of Interest
Women’s Health	Diabetes
Men’s Health	Heart Disease
Minority Health	Immunizations
STDs /HIV/AIDS	Tobacco Cessation
Lead Abatement	Obesity/Nutrition/Physical Fitness
Emergency Preparedness	Other:
Materials Requested
Flyers Brochures Giveaways None
Language Need (Bilingual staff and translated materials dependent upon availability.)
IDPH Contact Person
Contact Person:
E-mail:
Phone:
Additional information (1500 characters max):
Please submit completed form at least seven days prior to event.

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Illinois Department of Public Health
535 West Jefferson Street
Springfield, Illinois 62761
Phone 217-782-4977
Fax 217-782-3987
TTY 800-547-0466