McLean County PIO Group

2. Contact Information Survey
   The purpose of this survey is to collect McLean County PIO Group members' information. Data collected will be shared with the group for planning of an emergency situation when assistance is needed. A Picture Directory will be created to help identify all members of the McLean County PIO Group.

   The purpose of this survey is to collect McLean County PIO Group members' information. Data collected will be shared with the group for planning of an emergency situation when assistance is needed. A Picture Directory will be created to help identify all members of the McLean County PIO Group.

4. First Name*

5. Last Name*

7. Title*

8. Organization Name*

10. Organization Address 1*

11. Organization Address 2

13. City*

14. State*

15. Zip Code*

17. Primary Email Address*

18. Secondary Email Address

20. Primary Work Phone*

21. Secondary Work Phone

23. Primary Cell Phone*

24. Secondary Cell Phone

26. Picture*

    Please upload a head shot to be included in the McLean County PIO Group Member Directory

27. Media List

    If you have a media list you would like added to the universal McLean County PIO Group media list, please upload.

29. Please list your specialties (i.e. social media, media relations, writing, date mining, etc.)*

31. Emergency Planning

33. Are you willing to assist in another member's Joint Information Center (JIC), if needed?*

    1. Yes
    2. No

35. Please list your regular work hours*

36. Are you available on nights and weekends?*

    1. Yes

    1. No

38. Secondary Contact
    In the event that you leave your organization or change positions, please provide a secondary contact.

    In the event that you leave your organization or change positions, please provide a secondary contact.

40. Secondary Contact First Name*

41. Secondary Contact Last Name*

43. Secondary Contact Email Address*

44. Secondary Contact Phone Number*

46. Secondary Contact Title*

48. Miscellaneous

50. Does your organization have available space with technological connectivity to accommodate a Joint Information Center (JIC) should space be needed due to an emergency/disaster in the county? *

    1. Yes
    2. No

52. Please list your organization's address if different from above.

54. Comments

Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit

* indicates a required field