Community Projects Form
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Privacy Notice

We suggest you print out a blank form to use as a working copy. The information you provide will be entered into the H.E.R.E. in Washington on-line clearinghouse. Community Projects should involve health education or health promotion activities, have a public health or population-based focus, and be an approach other community health professionals in Washington might use or adapt. Information on your project should be current and available on request. Please fill out all portions of this form completely. We will contact you to verify the information before it is posted on the web site. Fill out a separate form for each project you wish to include. Please feel free to print copies of this form and share it with others in your agency.

   
Project Information New Update
Project Name
 		 
Lead Agency/Organization
Division
 		Section
Address
City
 		Zip
 		County
Contact Person
 		Title
 		 
Phone Numbers
Voice Fax
Email Address
   		Home Page Address
Preferred Method of Contact
Phone Fax Email Other
Project Start Date
End Date (if known)
Project Description - - Write a brief description of the purpose and main activities:
Briefly answer these questions
  1. Who conducts the project?
  2. What are the main activities?
  3. Who are these activities for (primary and secondary audiences)?
  4. Where is the project conducted and how often?
  5. What are the goals and objectives?
  6. Are there other activities or additional details?
  7. Are there other partners or sponsors?
  8. How was the project planned and evaluated?
  9. What are the sources of funding?

If the person completing this form is not the contact person for this project, please provide the following information so we can contact you with any questions:

Name:     Email:  
Phone:       Fax:      

Thank you for taking the time and effort to contribute to the success of this project. Your help and participation are greatly appreciated.

Comments or suggestions:
   

To mail or fax this form:
Office of Health Promotion
P.O. Box 47833
Olympia WA 98504-7833
 
Fax: 360-753-9100

Questions:
Don Martin
H.E.R.E. in Washington Coordinator
Voice: 360-236-3707
HERE@doh.wa.gov envelope icon indicating email address don.martin@doh.wa.gov

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Washington State Department of Health
Office of Health Promotion
P.O. Box 47833
Olympia, WA 98504-7833