PRC Region 9 Data Request Form

Prevention Resource Center Region 9- Data Request Form

Please fill out this form with your data requests
Name*

First NameLast Name
Organization Type
If you are a parent or youth, please select that option.
Email *
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
YesNO
DrugsAlcoholFentanylTobacco/Other Nicotine Products (Vape)Marijuana/THCPrescription DrugEducationCrimeMental HealthTeen BirthsTreatmentDemographicsRegional Needs AssessmentMilitaryStateRegional
AndrewsBordenCokeConchoCraneCrockettDawsonEctorGainesGlasscockHowardIrionKimbleLovingMcCollochMartinMasonMenardMidlandPecosReaganReevesSchleicherSterlingSuttonTerrellTom GreenUptonWardWinkler
Requesting Information Regarding:(Please be specific)
InfographicOne-PagerPower Point SlidesNarrative SummarySpreadsheet/GraphsSocial Media Post (to share on social media)One on One Meeting (in-person/virtual)EmailPhone call
When do you need the data request completed? (Please allow 7-10 business days when requesting. You will be contacted if it cannot be filled within that timeframe.) If you need it immediatley please contact the PRC directly at 432.580.5100.

MonthDayYear
Date
If you would like a formal Data Presentation for an event or agency, please contact the PRC directly at 432.580.5100 or email m.brenem@pbrcada.org.

www.reg9prc.org
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Prevention Resource Center Region 9- Data Request Form