UDS Event / Activity Form

School Name Lookup - use full name and/or department/organization.

City

State

If you are unable to locate your school above, please tell us your full school name and organization/department for proper activity credit.

City

State

Tell Us About the Event / Activity - one form is required for each activity, even if conducted on the same day

Which risk area did you cover? (Select one)

Distracted DrivingImpaired Driving

Which Distracted Driving Activity did you conduct?

Which Impaired Activity did you conduct?

Activity Date

Activity Location

On CampusOff Campus

Number of People Reached (Best guess)

Activity Description and Feedback

Please describe how you conducted the activity, such as the location, the time of day, who your audience was, and if you did any adaptations:

	Not likely	Likely	Most likely
How likely are you to do this activity again?

	Not engaging	Engaging	Very engaging
How engaging was the activity for your audience?

	Yes	No	Unsure
Do you think your audience learned something new with this activity?

How would you recommend improving this activity to fit your needs?

Submission Information

Submitter Name

Submitter Email

Payment Type - Gift cards are emailed to the primary contact of your department or organization who signed up originally for the program, and no W-9 is needed. If you select Check or ACH Payment, a W-9 is needed. Activity reward payments are made quarterly, (Oct, Jan, April and July)

Virtual Gift Card Check ACH Payment

File Uploads

Event / Activity Photo

By uploading a photo(s) through this form, I give Texas A&M Transportation Institute permission to use the image(s) to highlight and promote the educational and outreach activities I participated in. This may include, but is not limited to, use in reports, presentations, social media, websites and other promotional materials.

I understand that:

The photo may be shared publicly
I will not receive compensation for the use of the image
I can withdraw my consent at any time by contacting g-kolodzy@tti.tamu.edu

Do you consent to your image being used?

I consent to the use of my uploaded photo(s) as described above I do not consent to the use of my uploaded photo(s) as described above

By checking this box, I certify that all information submitted is true. I understand that my group will not receive payment until these forms are received and verified by the Texas A&M Tranportation Institute and a W-9 is received.

I confirm this form to be true and accurate.

UDS Activity Form Record Type ID