Materials Order Form

Would you like a USB Drive or DVD?*

USB Drive
DVD

First Name*

Last Name*

Title*

Phone*

Email*

Organization*

Mailing Address

Check if this is a home address.

This is a home address.

City*

State*

Zip Code*

How many employees in your organization:*

What is the nature of your organization? (Check all that apply)*

Police
Fire
EMS
Search/Rescue
Sheriff
Volunteer Fire
Combined Fire/EMS
Highway Patrol
Other (please explain below)

Other organization (please explain)

How will you use these safety materials? (Check all that apply.)

Safety meeting/training
New recruit
Other

Other uses (please explain):

What do you feel are the most important safety topics that need to be covered in training materials?

How much do you agree with each of the following statements?

LG&E, KU or ODP is committed to the safety of first responders like me.

The information LG&E, KU or ODP provides is valuable for keeping first responders safe around electricity and natural gas.

I expect LG&E, KU or ODP to provide first responders the information necessary to get their jobs done safely around LG&E, KU or ODP electric and natural gas infrastructure.

The first responders at my organization use LG&E, KU or ODP safety information to work more safely around electricity and natural gas.

The first responders materials provided by LG&E, KU or ODP help me and/or my coworkers perform their jobs more safely.

Internal Use Only

ID

BRC Code

Date (mm/dd/yy)

Project Category

Name

This field is for validation purposes and should be left unchanged.

In case of emergency, call 911 and LG&E, KU or ODP at 800-331-7370.

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