2. Please disregard the sign-in prompt above.
4. Please fill out this form only after the media inquiry has been fulfilled. If you have any questions, please contact Glen Barbour (glen.barbour@loudoun.gov or 703-771-5086) or the Public Affairs Office or (703-777-0113).
6. Date Received*
   Date Received
7. Media Outlet*
   -- Select One --APBlue Ridge LeaderLoudoun NowLoudoun-Times MirrorLoudoun TribunePatchPurcellville GazetteThe BurnWashington Business JournalWashington PostWinchester StarWRC-TV, NBC 4WTTG-TV, Fox 5WJLA-TV, ABC 7/NewsChannel 8WUSA-TV, CBS 9WDVM-TV WMAL RadioWTOP RadioOther
8. If other, specify media outlet.
10. Reporter/Editor/Producer Name*
11. E-mail address
12. Phone Number
14. What was the media outlet asking about?*
16. Name of the county employee who communicated with the media*
17. Name of person completing this form, if different
19. Your department*
    -- Select One --Animal ServicesBoard of SupervisorsBuilding and DevelopmentClerk of the Circuit CourtCommissioner of the RevenueCommonwealth's AttorneyCommunity CorrectionsCounty AdministrationCounty AttorneyCourtsEconomic DevelopmentElections and Voter RegistrationExtension ServicesFamily ServicesFinance and ProcurementFire and RescueGeneral ServicesHealth DepartmentHousing and Community DevelopmentHuman ResourcesInformation TechnologyJuvenile Court Service UnitLibrary ServicesMapping & Geographic InformationMental Health, Substance Abuse, and Developmental ServicesParks, Recreation, and Community ServicesPlanning and ZoningSheriff's OfficeTransportation and Capital InfrastructureTreasurer
20. Was more than one department involved in the inquiry?

    1. Yes
    2. No
21. If yes, other departments involved
    -- Select One --Animal ServicesBoard of SupervisorsBuilding and DevelopmentClerk of the Circuit CourtCommissioner of the RevenueCommonwealth's AttorneyCommunity CorrectionsCounty AdministrationCounty AttorneyEconomic DevelopmentElections & Voter RegistrationExtension ServicesFamily ServicesFinance and BudgetFire and RescueGeneral ServicesHealth DepartmentHousing and Community DevelopmentHuman ResourcesInformation TechnologyJuvenile Court Service UnitLibrary ServicesMapping & Geographic InformationMental Health, Substance Abuse, and Developmental ServicesParks and RecreationPlanning and ZoningSheriff's OfficeTransportation & Capital InfrastructureTreasurer
23. What did you say or information did you provide to the media?*
25. How long did it take to fulfill the inquiry?*
    -- Select One --Less than 24 hours24-48 HoursMore than 48 hours
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

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