HDSP Resource Form

Resource Information Form - PRIVACY INFORMATION!
In order to protect your privacy, we have included an option that you may check to keep your personal information off of the internet, however it will be stored with the Colorado Department of Public Health & Environment.

First Name

Last Name

Yes

No

Do you want your name to appear on the internet?

Organization:

Do you want your organization name to appear on the internet?

Yes

No

Address 1

Address 2

City

State

Postal Code

Do you want your address to appear on the internet?

Yes

No

Phone

Do you want your phone number to appear on the internet?

Yes

No

Email Address

Do you want your email address to appear on the internet?

Yes

No

Description/Abstract of Program or Project:

Counties Included in Project/Program (List up to 5):

CDC Priority Area Addressed: (Check up to 3)

Increase the Number of Adults Who Have High Blood Pressure Under Control

Increase the Number of Adults Who Have High Cholesterol Under Control

Improve recognition of signs and Symptoms and Importance of Calling 9-1-1

Improve EMS Response

Improve Quality of Care for Heart Disease and Stroke

Eliminate Health Disparities

Project does not fit with the CDC Priority Areas listed

CDC Goal Addressed:

Prevention of risk factors

Detection and treatment of risk factors

Early identification and treatment of heart attacks and stroke

Prevention of recurrent cardiac event

Disparity Addressed: (if applicable) (Choose up to 3)

Type of Program/Project: (Choose up to 3)

Setting:

Funding Source:

Status of Project:

Comments: (Please add any other information that you feel would be important for people to know)

Indicates Response Required