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Questionnaire

Organization:
Address:
City:
State: Zip:
Contact:
Phone:
Email:

The Community Agenda Snapshot report is a tool to engage the community by examining data and establishing priorities to improve health and human services in our community. We are tracking the utilization of the report to determine how it is used and how to improve the report for future use. Please let us know how your organization is using the Snapshot. Thank you.

Distributed the Community Agenda Snapshot to:
Board of Directors Leadership Team Staff Customers Others:

Hosted a Community Agenda presentation about the Snapshot:
No Yes Number Attending:

 

Snapshot report and/or Snapshot data was used for::
Funding Application Service Delivery Improvements Planning Other:

 

The Community Agenda framework consists of 5 focus/workgroup areas:
    A. Children and Youth
    B. Families and Neighborhoods
    C. Creating Independence for Elderly
    D. Creating Independence for Adults with Disabilities
    E. Health and Wellness

 

With which focus area does this organization’s mission most closely align (please select only one)?
A B C D E

 

Which focus area(s) does this organization’s services/programs address (select all that are appropriate)?
A B C D E

 

If your organization has any current projects that address one or more of these focus areas, which focus area?
A B C D E

    Example projects: Elderly Suicide Prevention Campaign, Diabetes Education Event, Domestic
    Violence Prevention Event
    If yes, project title(s):

 

The Snapshot includes special coverage on three topics—Information & Referral, Poverty and Transportation. Has your organization used the Snapshot to address any of these issues and if so, how?
Information & Referral How?
Poverty How?
Transportation How?

 

 


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