Healthier WI Partnership Program

Healthier WI Partnership Program

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Community Partner Intake Form

This form should be used by community organizations who are willing to be listed in our web-based partner directory.  Participation is voluntary and not necessary for proposal submission.

By joining this directory, you agree to be open to direct communications with individuals who utilize the directory for the purpose of formulating partnerships and discussing potential projects that will improve the health of Wisconsin residents. 

HEALTH IMPROVEMENT PRIORITIES

The areas identified below are based on the health improvement priorities identified by the Healthier Wisconsin Partnership Program, informed by the Healthier Wisconsin 2020 state health plan. Please indicate your areas of interest and / or expertise, checking all areas that apply. Use the Control key along with your mouse to chose multiple options.

1. Infrastructure focus areas to transform health improvements:

 

2. Populations affected:

 

3. Health focus areas:

  

4. Briefly describe any 'other' selections checked above:

 

 

PARTNERSHIP EXPERIENCE

Briefly describe any experience with community-medical college partnerships that you have had.

 

 

PROJECT DESCRIPTION

If you are actively working on a specific project or program idea that may include faculty partners, briefly describe it here.

 

 

GEOGRAPHIC EMPHASIS

Please indicate the area of Wisconsin that most closely reflects the geographic emphasis area of your project.

 

CONTACT INFORMATION

Organization (required field):

Contact Name (required field):

Address (required field):

 

Phone:

E-mail (required field):

Would you like your email address to be added to the HWPP electronic distribution list?

 Yes No

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Page Updated 02/21/2013