Public Health Coalition Needs Assessment
The Public Health Coalition is collecting information from the public in order to determine the level of interest in different mapping tools.
First and Last Name *
Email *
Which community (town, city, region, state, etc) are you referencing when filling out this form? *
On a scale of 1-5 (1 = very little; 5 = very much), to what extent does your community engage with the local topics regarding... *
1
2
3
4
5
Physical Health
Mental Health
Sexual Health
Relationship Health
Gun Violence
Primary School Education
Homelessness
Tobacco/Alcohol/Drug Use
Police Brutality
Minority Healthcare Needs
Food Security
On a scale of 1-5 (1 = very little; 5 = very much) to what extent would your community benefit from a mapping tool highlighting efforts towards... *
1
2
3
4
5
Physical Health
Mental Health
Sexual Health
Relationship Health
Gun Violence
Primary School Education
Homelessness
Tobacco/Alcohol/Drug Use
Police Brutality
Minority Healthcare Needs
Food Security
Is there another topic in your community that would benefit from a mapping tool?
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy