Exit this survey Coalition Member Feedback Form Question Title * 1. Name Question Title * 2. What have you done differently in the past month due to your involvement with the coalition? Please include date and action. Date Action Date Action Date Action Date Action Question Title * 3. What actions can you take in the next month to further the work of the coalition in relationship to the coalition priorities? (only when it is completed can it be counted as an output) Intended Action Intended Action Intended Action Intended Action Question Title * 4. What activities have you engaged in to affect the priorities of the coalition? (only those that are done because of coalition involvement can be counted as an output) Date Action Date Action Date Action Date Action Question Title * 5. Other information that could be helpful to the coalition: Done