Consumer Research for Nutrition Educatoin and Promotion Activities (SLT)

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

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0584-0524. The time required to complete this information collection 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.

Form FNS-808 (06/16) Previous Editions are Obsolete

SBU

Electronic Form Version Designed in Adobe 10.0 version