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* 1. Name of your institution:

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* 2. Your name:

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* 3. The department or division you belong to:

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* 4. Mental Health Program or Service that would be the  focus of the evaluation:

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* 5. Brief description of any specific focus of your evaluation- one aspect or element of the service and the key questions you want want to answer through the evaluation:

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* 6. Will this pilot be conducted and involve one department or engage others? If others, who?

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* 7. How do you plan to dedicate time to work with a champion? Will there be a dedicated  person on campus to work with the champion? Will it be shared amongst the team?

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* 8. How will you plan to dedicate time to work with a champion? Will there be dedicated hours per month for the project?

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* 9. How would you describe the current strengths/weaknesss and areas of growth and learning regarding evaluation?

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* 10. What is your instiution interested in this project now?

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* 11. Does your institution and or campus have a broader mental health strategy?

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