| Step 1: Assessment |
■ The assessment phase helps define the problems or the issued that coalitions need to tackle.
■ This phase involves the collection of data to understand the population's needs, review the resources that are required and available, and identify the readiness of the community to address prevention needs and service gaps.
■ Coalitions should have representation from their community and include a minimum of one member from each of the targeted areas.
■ Active coalition members listed in Section 10 are defined as a representative from the community who participates in regularly scheduled coalition management and planning meetings and is an active participant and contributor to the coalition's activities, events, and strategic planning. Individual coalition members may not represent more than one category.
■ Please complete all fields and submit.
|
| |
| 1. Coalition affiliation |
| 2. Enter your name |
| 3. LiveWise regional representative |
| 4. Community snapshot completed Yes No |
| If yes, date completed. | | |
| 5. Service areas/populations identified Yes No Please check all groups involved in the coalition. |
| Businesses | Yes No | Civic/Volunteer Groups | Yes No |
| Coalitions | Yes No | Law Enforcement | Yes No |
| Schools | Yes No | Religious/Fraternal | Yes No |
| Media | Yes No | Healthcare/Social Services | Yes No |
| Parents | Yes No | Youth-Serving Organizations | Yes No |
| Youth (18 or under) | Yes No | Government - Local | Yes No |
| Government - State | Yes No | Government - Tribal | Yes No |
| 6. Mission statement completed Yes No |
| 7. Bylaws completed/renewed Yes No |
| If yes, date completed/renewed | | |
| 8. Training needs assessment completed Yes No |
| If yes, date completed | | |
| 9. Gap analysis completed Yes No |
| If yes, date completed | | |
| 10. Total coalition members |
| Sustaining | New | Advocate |
| Paid/volunteer members of the coalition and number: Please list names in Section 12. |
| Business | # | Civic/Volunteer Groups | # |
| Coalition | # | Law Enforcement | # |
| Schools | # | Religious/Fraternal | # |
| Media | # | Healthcare/Social Services | # |
| Parents | # | Youth-Serving Organizations | # |
| Youth (18 or under) | # | Government - Local | # |
| Government - State | # | Government - Tribal | # |
| 11. Organizational capacity. Please provide the name and title of the coalition leadership. |
Facilitator | Notetaker |
President | Vice President |
Secretary | Treasurer |
Name | | Required Yes No |
Name | | Required Yes No |
Name | | Required Yes No |
Name | | Required Yes No |
Name | | Required Yes No |
Name | | Required Yes No |
12. Additional information or clarification.
|
|
| |
|
Disclaimer Ι Privacy Notice
Region 6 programs accredited by CARF are the Regional Prevention Center, Professional Partner Program, and The Spring Center.
Copyright © 2006. Region 6 Behavioral Healthcare. All rights reserved. |
