Partnership Proposal Form

Name of Individual Filling Out Form(Required)

Email of Individual Filling Out Form(Required)

Partnership Proposed(Required)

Please include a description of the partner, partnership and why it is being proposed.

Partnership Start Date(Required)

Please note relevant APA programs, networks, and/or individuals the partnership would affect.(Required)

Please include any resources needed to achieve the proposal.(Required)

Including but not limited to program changes, software, staff support, etc.

Health Equity Assessment

Who does your partnership or program impact directly or indirectly?(Required)

Immigrant and/or refugee populations

Individuals underrepresented in medicine

LGBTQ+

Improve Language-Appropriate Healthcare for All

Low income families

Please indicate other populations and/or communities impacted:

Please include how the proposed partnership or program will impact the groups noted/selected above.(Required)

If the partnership does not impact the groups above, note how the partnership could advance equity.(Required)

Put NA if equity is advanced.

Identify potential positive and negative impact(s) or unintended consequences for the identified population the parternship serves:(Required)

Given your responses above, which actions will you incorporate into your partnership proposal to advance equity and reduce negative impacts?(Required)

Partnership Proposal Form

Partnership Proposal Form

Health Equity Assessment

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