Resource Download

Following completion of this survey, you will be able to access a PDF version of the PSE Playbook. If you would like to receive a hard copy of the playbook, you can indicate that in the form below. 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 *

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 *

7. Do you want a hard copy mailed to you?

Yes

No

How many copies?

The maximum number of hard-copy PSE Playbooks is five per person

First Name

Last Name

Address

Address (optional)

City

State

Zip Code

8. I would like to subscribe to the Champion Provider Fellowship e-newsletter *

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

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Champion Provider Fellowship