Name of GWEP Site

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* 1. Name of GWEP Site

Contact Information

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* 2. Contact Information

Briefly describe the GWEP program goal(s) that are relevant to this request.

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* 3. Briefly describe the GWEP program goal(s) that are relevant to this request.

How will this consultation help you achieve your program aims and objectives? (Please be specific)

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* 5. How will this consultation help you achieve your program aims and objectives? (Please be specific)

What is the local need addressed by the proposal? Describe the gap in care that you are aiming to fill. (Provide any relevant data)

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* 6. What is the local need addressed by the proposal? Describe the gap in care that you are aiming to fill. (Provide any relevant data)

When implemented, what is the anticipated impact that the program would have on the health care environment or community?

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* 7. When implemented, what is the anticipated impact that the program would have on the health care environment or community?

Submit a general timeline for consultation and possible implementation.

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* 8. Submit a general timeline for consultation and possible implementation.

Following a consult, what do you anticipate as your next step(s) to move the program forward?

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* 9. Following a consult, what do you anticipate as your next step(s) to move the program forward?

Have you identified a champion within your health care system or community (as applicable)? A champion outside of the GWEP leadership may be needed to assist in program implementation. If so briefly describe that individual (role, title) and why is this individual a good fit for the project.

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* 10. Have you identified a champion within your health care system or community (as applicable)? A champion outside of the GWEP leadership may be needed to assist in program implementation. If so briefly describe that individual (role, title) and why is this individual a good fit for the project.

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