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Dermascan Evaluation Form
To get started, please enter your name and your email address.
Date of Event
Title of person providing education with the dermascan machine
Names of additional staff that used the dermascan, if applicable? Please include hours worked and title
Number of hours dermascan was used
Number of people reached
Please indicate your organization type and specify in the box below your agency name and/or section
University or College
Local Public Health Unit
Public or Private Primary School
Health Care Facility
Federally Qualified Health Center
Briefly describe the event or activity
Describe Activity Response, including but not limited to: Your evaluation of the dermascan machine and effectiveness, participant response, etc.
Would you recommend using this machine to others to educate about UV Safety and Skin Cancer Prevention?
This field is for validation purposes and should be left unchanged.
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600 East Boulevard, Department 301, Bismarck, ND 58505-0200
701.328.3398 | 701.328.2036-fax
NORTH DAKOTA DEPARTMENT OF HEALTH