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 OK Question Title * 1. Name: OK Question Title * 2. Organization: OK Question Title * 3. Title/Program: OK Question Title * 4. Work E-mail Address: OK Question Title * 5. Phone Number: OK Question Title * 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): OK Question Title * 7. Please give a brief description of your organization and/or program’s activities: OK Question Title * 8. Are you currently applying for any grants? No, not at this time Unsure Yes (please specify): OK Question Title * 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): OK Question Title * 10. May we showcase your organization on Healthy Pima's Community Wellbeing page? Yes No, not at this time OK Question Title * 11. Are you interested in learning about other organizations that offer similar programs / services? Yes No, not at this time OK 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). Yes, by phone Yes, by e-mail No, not at this time OK Question Title * 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: OK Question Title * 14. Additional information or comments (if any): OK THANK YOU!