CHIP - Scorecard Action Guide Form

- 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.

List each Activity or Project - you can include up to four. (If you have more than four activities, simply submit a second form).
For each Activity, enter a concise Description of your organization’s services or programs that address this issue.
Note any specific Target Population this activity targets (i.e. Elderly, disabled, Hispanic etc…)
List any Goals and/or objectives your organization has for this activity over the next few years.

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