COACH Program Application 2017
Thank you for your interest in the COACH Program through the Healthy Wisconsin Leadership Institute. The COACH Program is a capacity building program for teams who are doing policy, systems, and environmental change work in their communities. If you have questions about the program, please contact Shor at salkas@wisc.edu.
Email address
Name of community:
Your answer
Name of coalition or partnership and its mission:
Your answer
Priority health issue:
Your answer
Which of the Health Focus Areas outlined in Wisconsin’s State Health Plan, Healthiest Wisconsin 2020, does your coalition/partnership address? For more information on state health plan priorities, visit http://www.dhs.wisconsin.gov/statehealthplan/
In the following questions, we would like to get to know more about your coalition/partnership. Please answer the questions below with as much detail and specificity as you can provide. This will help us determine how we might best meet your community’s needs.
When was the broader coalition/partnership that your team represents formed? (month and year)
Your answer
How many members are there in your coalition/partnership?
Your answer
Who/what sectors does your membership represent? (check all that apply)
Who are other stakeholders your partnership would like to engage?
Your answer
How does your coalition/partnership engage people most affected by the community health problem?
Your answer
How does your coalition/partnership apply a health equity approach to your work?
Your answer
What is your coalition/partnership structure and who provides leadership?
Your answer
What is your process for making decisions in your coalition/partnership?
Your answer
Are you currently utilizing community organizing in your work?
Are you currently utilizing collective impact in your work?
Please share any additional information that you feel is relevant about your coalition/partnership.
Your answer
Please describe any interventions/initiatives that your coalition/partnership is currently working on, and whether they are part of a strategic plan for policy, systems or environmental change (PSE).
Your answer
Please list the top recent accomplishments of your coalition/partnership and at least two outcomes you seek to accomplish during the next three years. (Please attach an action and evaluation plan if already developed.)
Your answer
Briefly describe the top challenges of your coalition/partnership so far.
Your answer
How will the coalition/partnership likely benefit from your participation in the COACH Program?
Your answer
Please describe what skills you hope to learn while in the COACH Program. Below is a list of some of the training and coaching HWLI coaches and consultants can provide to COACH teams.
Your answer
How will the team communicate and share its learning experiences with the broader coalition/partnership?
Your answer
Team Member Roster
1. Team Member Name (Team Contact):
Your answer
Agency/Organization (if applicable):
Your answer
Mailing Address:
Your answer
Email Address:
Your answer
Phone:
Your answer
Past Community Teams Program participant?
Contributions to the team and coalition (skills, knowledge, perspective, connections, resources):
Your answer
What do you hope to gain by participating in the COACH Program (learning needs and expectations):
Your answer
2. Team Member Name:
Your answer
Agency/Organization (if applicable):
Your answer
Mailing Address:
Your answer
Email Address:
Your answer
Phone:
Your answer
Past Community Teams Program participant?
Contributions to the team and coalition (skills, knowledge, perspective, connections, resources):
What do you hope to gain by participating in the COACH Program (learning needs and expectations):
Your answer
3. Team Member Name:
Your answer
Agency/Organization (if applicable):
Your answer
Mailing Address:
Your answer
Email Address:
Your answer
Phone:
Your answer
Past Community Teams Program participant?
What do you hope to gain by participating in the COACH Program (learning needs and expectations):
Your answer
4. Team Member Name
Your answer
Agency/Organization (if applicable):
Your answer
Mailing Address:
Your answer
Email Address:
Your answer
Phone:
Your answer
Past Community Teams Program participant?
Contributions to the team and coalition (skills, knowledge, perspective, connections, resources): What do you hope to gain by participating in the COACH Program (learning needs and expectations):
Your answer
What do you hope to gain by participating in the COACH Program (learning needs and expectations):
Your answer
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