- Information Form

 

health (hĕalth) n.: a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

The Community Health Improvement Partnership, or CHIP, is interested in learning about how your organization is working to impact the health of Sarasota County residents.  We are hoping to capture information relating to broad domains of health, including individual behaviors, the social environment, physical environment, health care availability and access, and disease and injury. The information you provide will be used to create a comprehensive guide of what is being done to improve health on a local level. We hope this information can be used to help network organizations working on similar issues and identify gaps in services or resources.
 


Please provide the following contact information:

Name of Organization:
Name of Contact: Title:
Street Address:
Address (cont.):
City: State: Zip:
Phone: Email:
Website:

 

Does your organization work to impact the health of local residents?

Yes No

 

If yes, please use the following fields to provide information for each health related activity or project that your organization currently offers.


Activity or Project: 
   
Description:
   
Target Population:
   
Goals:

Activity or Project:
   
Description:
   
Target Population:
   
Goals:

Activity or Project:
   
Description:
   
Target Population:
   
Goals:

Activity or Project:
   
Description:
   
Target Population:
   
Goals:

When you have finished filling out the form, press "Submit Form".  To start over, press "Reset Form".


Revised: 06/30/08