Healthy Pima Submission Form

Be recognized for what you do in our community!

We know that there are so many vital organizations like yours that provide health, wellness and preventative services in Pima County. We also know how hard it is to get the word out, especially to those who could benefit from your specific assistance and expertise.

Healthy Pima wants to connect you to your community and to community partners whose interests align with yours! Whether you are looking to collaborate on an initiative, partner on a grant application, or influence public policy, Healthy Pima wants to connect you with like-minded organizations working to address the health needs of the community.

There is no catch and no cost. Simply put, the information you provide will assist the Healthy Pima Initiative not only by improving awareness and access to existing services like yours but also by identifying where there are still gaps in essential services needed to build a healthier community.

Please take a few minutes to complete this survey, get connected and be recognized.

For questions or more information, please contact: HealthyPima@pima.gov

As always, thank you for all that you do!

Please note: Personal information such as phone numbers and e-mail address are not listed on the Healthy Pima website to protect our valued community partners from solicitation and unwanted contact. All information collected from our community partners is stored in a secure government database and is only shared with agency’s working to improve population health. You can choose to opt out any time by e-mailing us at: HealthyPima@pima.gov

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* 1. Name:

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* 2. Organization:

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* 3. Title/Program:

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* 4. Work E-mail Address:

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* 5. Phone Number:

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* 6. What area(s) of health/wellness does your organization address? (Please select all that apply)

Access to Health Services

Aging

Asthma

Boarder Health

Crime

Diabetes

Emergency Preparedness & Response

Employment

Environmental Health

Food Security

Handicap Access

Housing and Health

Interpersonal Violence

Older Adults

Parks & Recreation

Pedestrian Access

Physical Activity and Nutrition

Poverty

Refugee and Migrant Communities

Reproductive Health

Rural Health

Safety

School Health

Smoking and Tobacco Use

Trauma

Transportation

Workplace Health Promotion

Youth Development

Other:

Other (please specify):

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* 7. Please give a brief description of your organization and/or program’s activities:

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* 8. Are you currently applying for any grants?

No, not at this time

Unsure

Yes (please specify):

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* 9. I am interested in collaborating with other community partners on:

Advocacy Work

Brainstorming / Sharing Ideas

Education / Training Opportunities

Expert Testimony / Consultation

Grant Applications

Influencing or Developing Public Policy

Pooling Resources

Research

Relationship Building

Starting a Coalition

Technical Assistance

N/A

Other (please specify):

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* 10. May we showcase your organization on Healthy Pima's Community Wellbeing page?

Yes

No, not at this time

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* 11. Are you interested in learning about other organizations that offer similar programs / services?

Yes

No, not at this time

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* 12. May we contact you regarding new programs, initiatives, ideas, or funding opportunities that we think may benefit your organization? (You can choose to Opt Out any time).

Yes, by phone

Yes, by e-mail

No, not at this time

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* 13. Do you know of someone that would benefit from being a part of Healthy Pima? If so, please provide us with their name and e-mail address below and we will send them an invitation to participate!

No, not at this time

Yes, please send the contacts below an invitation to participate in Healthy Pima:

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* 1. Name:

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* 2. Organization:

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* 3. Title/Program:

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* 4. Work E-mail Address:

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* 5. Phone Number:

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* 6. What area(s) of health/wellness does your organization address? (Please select all that apply)

Question Title

* 7. Please give a brief description of your organization and/or program’s activities:

Question Title

* 8. Are you currently applying for any grants?

Question Title

* 9. I am interested in collaborating with other community partners on:

Question Title

* 10. May we showcase your organization on Healthy Pima's Community Wellbeing page?

Question Title

* 11. Are you interested in learning about other organizations that offer similar programs / services?

Question Title

* 12. May we contact you regarding new programs, initiatives, ideas, or funding opportunities that we think may benefit your organization? (You can choose to Opt Out any time).

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* 13. Do you know of someone that would benefit from being a part of Healthy Pima? If so, please provide us with their name and e-mail address below and we will send them an invitation to participate!

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* 14. Additional information or comments (if any):