Your Name: Your Last Name: 

Community: County:   State:

Congressional District:

Name of your Organization: (if someone other then yourself)

Name of Organization contact if other then yourself:

Your Contact Address (line 1):

Address (line 2):

City: State: Zip:

Telephone: Fax:

Email:

Community Coalition Partner Contact Information: (If you are affiliated with a Coalition please fill out this contact information.)

Community Coalition Name:
Coalition Contact person (if other then yourself):

Address (line 1):

City: State:  Zip:

Telephone: Fax: Email:

Please provide a brief description of your community coalition.

Please describe measurable objective(s) related to access or disparity that your community coalition wishes to achieve.

Based upon the ten-step Community Progress Scale, at which step would you gauge your community's progress?

What type of assistance do you need to achieve your goals? (Press Ctrl to select multiple types)

Community Needs Assessments Free policy publications to aid in your coalition work and development National teleconferences on topics pertinent to your efforts Free tools and techniques for gathering and evaluating information in your community Coaching on how to put local information to use in improving your health system and sustaining the changes Board Development/Training Strategic Planning Integrated System Development Coalition Building, Networking Referrals to other expert organizations to help in many technical areas vital to ensuring network success Alternative Funding Approaches Knowledge of other Organizations/coalitions doing similiar work in your area Peer- to - Peer Grassroots Consultations Coaching on how to involve community residents in your coalition Coaching on how to educate public policy makes about the importance of access of health care OTHER (enter explanation below)

OTHER: enter the type of assistance that is needed to achieve your goals: 

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