Statewide Capacity Collaborative Leadership Development Survey

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* 1. As the individual submitting feedback, please share the following

Name

Organization or Community

Role of Title if appplicable

Email Address

Phone Number

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* 2. Would you like to be contacted with any follow up?

Yes

No

Yes, but please use the following contact information:

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* 3. Please tell us about the group of people that participated in the discussion in the comment boxes below (include yourself): please skip if just yourself

How many people were present?

How many different organizations were represented?

How many different racial/ethnic communities were represented?

How many different gender indentities were represented?

What languages were spoken?

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* 4. Which zip codes were represented in your group discussion?

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* 5. If your notes from a group discussion please identify in the comment box below how group discussion participants identified themselves as a leader by giving as the total for each category (please include yourself):

Emerging Leader

Established Leader

Community Leader (urban or suburban)

Community Leader (rural)

Youth/Young Adult (under the age of 25)

Other

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* 6. What are the main recommendtions that came out of this discussion?

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* 7. Please upload your Demographic Information Sheet

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

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* 8. If you cannot upload your Demographic Information Sheet, please list the information below.

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* 9. Please upload all Notes from your discussion.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

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* 10. How did you hear about this opportunity?

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* 11. Additional comments or feedback from your group discussion, experience, etc. that was not captured above.

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* 12. Please upload any additional documents.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.