Local Collaboration/Project Profile Data Collection Form
This information will help us build a project profile on the All In: Data for Community Health virtual collaboration platform at
. Please visit the site and register your individual profile with the collaboration/project name so that you will be linked to the project group. Encourage other participants to join by visiting
and using the same collaboration/project name.
Location of collaboration/project (city, state)
Please provide the name of the lead organization(s) for this project.
Please provide the name of the key stakeholder organization(s) for this project.
Please submit the name and email of main contact for managing your collaboration/project group at
(if different from above).
Please give a short narrative description of your collaboration/project.
What best describes the lead organization of your collaboration/project?
Community-based organization or non-profit
Collaboration backbone organization
What sectors are included in your collaboration/project?
Clinical Health Care
Health Care Payers
Information Management Infrastructure
Mental/Behavioral Health Care
Public Safety/Law Enforcement
Tribal/Local/State Government Agencies
If your collaboration/project has a health focus, please select from the following:
Other Chronic Conditions
Unintentional Injury and Poisoning
Violence / Intentional Injury and Poisoning
If your collaboration/project is sharing (or planning to share) data, what types of data are being shared?
Community-generated surveys and assessments
Research-generated surveys and assessments
Personally Generated Health
Service (case management)
Rankings and Indicies
What is the anticipated impact level of your project?
Individual / Family
Community / Place
Policy & System
Culture / zeitgeist
If you are targeting a certain population, please indicate below:
Children (under 18)
Expectant mothers and infants
Multiple chronic conditions
Other vulnerable populations
Racial and ethnic minorities
How is your project funded?
Please provide links to any logos, artwork, or resources you would like to appear on the collaboration/project page.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service