2017 Monthly Data Clinic Application
Email address *
Organization
Your answer
Contact Name
Your answer
Address
Your answer
Phone
Your answer
Website
Your answer
Mission (Program Description)
Your answer
Geographic Service Area (town/city, county, region, state+)
Your answer
Number of staff (include FT and PT)
Your answer
Organization Type (check all that apply) *
Required
Monthly clinics are offered from 10:00am - 12:00pm at the Wishcamper Center on the University of Southern Maine campus in Portland, ME. Please indicate all the dates when you and your team are available. *
Required
Does your organization or program have a theory of change/logic model? *
Does your organization or program have a current strategic plan, marketing plan, continuous quality improvement plan, data collection plan or evaluation plan? *
What two topics would you most like to discuss during a clinic? *
*
Please describe more specifically your data issue(s) or question(s). *
Your answer
Is there any other information we need to know about your data or evaluation needs?
Your answer
After reviewing this application, we will contact you to confirm a slot and request additional materials. If you have any questions, please contact Becky Wurwarg at rebecca.wurwarg@maine.edu.
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
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