* 1. Name

* 2. What have you done differently in the past month due to your involvement with the coalition? Please include date and action.

* 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)

* 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)

* 5. Other information that could be helpful to the coalition:

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