Following completion of this survey, you will be able to access a PDF version of the Toolkit. Information collected in this survey is for our program evaluation purposes. Items with a red asterisk (*) indicate required fields 1. Affiliated Organization 2. Organization Classification Hospital/Clinic Health System Federally Qualified Health Center Community Based Organization Local Health Department Education (Pre-K – 12) University/Academic Institution Other If Other, please specify 3. County - Select -Alameda CountyAlpine CountyAmador CountyButte CountyCalaveras CountyColusa CountyContra Costa CountyDel Norte CountyEl Dorado CountyFresno CountyGlenn CountyHumboldt CountyImperial CountyInyo CountyKern CountyKings CountyLake CountyLassen CountyLos Angeles CountyMadera CountyMarin CountyMariposa CountyMendocino CountyMerced CountyModoc CountyMono CountyMonterey CountyNapa CountyNevada CountyOrange CountyPlacer CountyPlumas CountyRiverside CountySacramento CountySan Benito CountySan Bernardino CountySan Diego CountySan FranciscoSan Joaquin CountySan Luis Obispo CountySan Mateo CountySanta Barbara CountySanta Clara CountySanta Cruz CountyShasta CountySierra CountySiskiyou CountySolano CountySonoma CountyStanislaus CountySutter CountyTehama CountyTrinity CountyTulare CountyTuolumne CountyVentura CountyYolo CountyYuba CountyOther If out of state please select other If other county or state please specify 4. Are you a current or former Champion Provider Fellow? Yes No 5. Are you a local health department representative? Yes No 6. How did you learn about this resource? Referral from a colleague Internet Search CPF Website Other If Other, please specify 8. I would like to subscribe to the Champion Provider Fellowship e-newsletter Yes No Email Address Enter email 9. I agree to be contacted to participate in a brief survey about my experience using this resource. Yes No Email Address Enter email CAPTCHA Get new captcha! What code is in the image? Enter the characters shown in the image. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Leave this field blank
