CHPP Media Interview Request Form
Name
First Name
Last Name
News Outlet
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Interview Date Request
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Interview Time
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Total 0.0
Alternative Interview Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Interview Length
ex: 00:30
Deadline to Confirm Interview
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Interview
Face-to-face / In person
Telephone Landline
Cellphone/Facetime
Skype
Zoom
Instagram
Facebook
Other
Location and reach of outlet
Social Media Handles
Name of desired interviewee or area of expertise
Questions/Discussion Topics
Special Requirements
Other comments/Questions
Submit
Should be Empty: