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Workplace Health Promotion Service Request Form To arrange a consultation or regional workshop, complete the form below or please print off a PDF version of the request kit and send it to us . We will work with you to develop a plan for the consultation that will best meet your needs. Please note: These services will be on first come first serve basis and will only be available for the time that the project is in effect. 1. Applicant Information First Name Last Name Organization Job Title Address City Province THCU services are available free to residents of Ontario only Postal Code Telephone Tel. Extension Fax Email Please select whether you would like to receive information by Fax or Email 2. What type of organization are you representing? Board of Health, Health Unit or Department Community Coalition - Focus Community Coalition - Heart Health Community Coalition - Other OHPRS Member Provincial Resource Centre - Other Community Health Centre NGO / Voluntary Group Government - Local Government - Provincial Government - Federal Hospital Medical Organization - Other Workplace Schoolboard District Health Council CCAC Post Secondary Staff Post Secondary Faculty Student Freelance Other 3. Please identify your Ministry of Health Promotion region. East Toronto Central South Central West North Central East South West Out of Ontario Out of Canada Other Don't Know 4. Please describe your role within your organization (please check all that apply). Health promoter/educator Public health nurse Nutritionist/dietician Public health inspector Manager/supervisor Other (please specify) 5. Please select the type of assistance you need from the following list (one or more). Workshop Short Training Session Facilitation Advice Feedback on your work Information and Resources Other (please describe): 6. Briefly describe the situation in your community or agency and explain what you want to accomplish through this consultation. 7. Have you spoken to anyone from THCU about this topic/consultation already? If so, who, and (briefly), what was discussed? 8. Preferred timing for the consultation? 9. Are you willing to pay some or all travel costs associated with this service request? Yes No Don't Know Not Applicable Comments 10. Anything else you'd like us to consider? For more information, please contact: The Health Communication Unit at the Centre for Health Promotion University of Toronto, The Banting Institute 100 College Street, Room 213 Toronto, Ontario M5G 1L5 Tel: 416-978-0595 Fax: 416-971-2443 workplace_admin@thcu.ca
To arrange a consultation or regional workshop, complete the form below or please print off a PDF version of the request kit and send it to us . We will work with you to develop a plan for the consultation that will best meet your needs. Please note: These services will be on first come first serve basis and will only be available for the time that the project is in effect.
Board of Health, Health Unit or Department Community Coalition - Focus Community Coalition - Heart Health Community Coalition - Other OHPRS Member Provincial Resource Centre - Other Community Health Centre NGO / Voluntary Group Government - Local Government - Provincial Government - Federal Hospital Medical Organization - Other Workplace Schoolboard District Health Council CCAC Post Secondary Staff Post Secondary Faculty Student Freelance Other
East Toronto Central South Central West North Central East South West Out of Ontario Out of Canada Other Don't Know
Health promoter/educator
Public health nurse
Nutritionist/dietician
Public health inspector
Manager/supervisor
Other (please specify)
Workshop
Short Training Session
Facilitation
Advice
Other (please describe):
Yes No Don't Know Not Applicable
Comments
For more information, please contact:
The Health Communication Unit at the Centre for Health Promotion University of Toronto, The Banting Institute 100 College Street, Room 213 Toronto, Ontario M5G 1L5
Tel: 416-978-0595 Fax: 416-971-2443 workplace_admin@thcu.ca
