FNS-808 Power Panther Costume Event Feedback Form

OMB APPROVED NO. 0584-0524
Expiration Date: XX/XX/XXXX
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Power Panther™ Costume
Event Feedback Form
Date:

Name of Agency:

Person Completing Feedback Form:
E-mail Address:

Phone:

Please describe the event where Power Panther™ costume was used:
Name of Event:

Date of Event:

Type of Event:

Location of Event (include City and State):

Focus/Objective of Event:
Main Message of Event (if different from focus):
Age/Grade:

Target Audience for Event (e.g., children, teen):
Describe Target Audience (e.g., from what school, club or program):
What Did Power Panther™ Do at the Event?
Honored Guest/Speaker(s) (if applicable):
Main Message Related by Guest/Speaker(s) (if applicable):
Approximate Number of Children Who Attended:
Was Your Event Successful?

Yes

Approximate Number of Adults Who Attended:

No Please explain:

Would you use Power Panther™ in the Future?

Yes

No

If no, why not?

State

Name (optional)

Eat Smart. Play Hard.™
United States Department of Agriculture • Food and Nutrition Service

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of 9
information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research
and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0524). Do not return the completed form to this address.

Form FNS-808 (03/10) Previous Editions are Obsolete

SBU

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