PROFILE OF AREA TARGETED

Targeted Community:

Type Of Area:

Urban
Suburban
Rural

Estimated Population of Target Area:

Description Of Target Population
Describe the characteristics of the target population served
in the year in terms that are important for your coalition work. (Example: age, ethnicity, level of exposure to drugs, incidence of risk factors, etc.)

Needs Assessment
Describe the needs, gaps in services, problems and or
 risk factors identified that lead the work of the coalition.

Coalition's Major Accomplishment
What were some of the major accomplishments
 of this coalition?

Active Member Profile
Under Area of Involvement, please enter all that correspond.
 

Name of Organization

Type of
Organization

Main
Activity

Years In
Coalition

Area Of
Involvement

Name and title of person reporting environmental change:

Name of coalition represented:

Environmental Change:
Describe briefly the environmental change, not the activities implemented.

Description Of The Problem, Need Or Gap Identified:
Describe the problem, need or gap identified that lead to this environmental change.

Type of change (select all that apply):

Physical infrastructure changed   
Social norms and attitudes changed  
Supply of substances changed        
Delivery of services changed      
Policies changed                    
Procedures changed                  
Laws and/or ordinances changed      
Leadership structures changed     
Community risk-factors changed 
Other (please specify) 

Social institutions changed (select all the apply):

Local, state or federal government                 
Local school districts                             
Private business and corporations                   
Public or private healthcare organizations        
Law enforcement organization                        
Community-based or grass-root organizations         
Non-governmental social service and/or              
educational organizations                         
Civil associations (e.g., Rotary Clubs, League of Women Voters, etc.) 
Religious organizations, churches, and/or           
faith-based organizations                         
Political groups, organizations, and/or parties.
Other (please specify) 

What Level Of Environment Was Impacted By This 
Change?

Select the option that is most appropriate for the change described.
 School district 

 Neighborhoods 

 City 

 County 

 Region or multi-county 

 State 

 National 

 International 

Importance Of This Environment Change

Describe briefly how this change will affect the target community


Impact Of The Environmental Change:

Report specific verifiable and quantifiable information about the
benefits obtained by the community attributable to the environmental
change described.

Brief Description of the Role Played by the Coalition To Attain Change Described:
        

Other Parties and/or Organizations Involved in this Change and Brief Description of the  Role Played by the Partner(s)
        

 

Thank you for your interest in partnering with ACC We look forward to partnering with you.
                                      -Alternative Choice Corporation