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Data Collection Worksheet Template
Statistical Information is from what City or County:
SECTION ONE: Data Collection
Data from Your
(City or County)
Data for US *
Overall population of area of focus
Population under the age of 5
Population over the age of 65
Population of male and female
Percentage of non-native speaking population/ households
HEALTH RELATED DATA
10 diseases with the highest mortality (or prevalence)
* International students – data from your country
SECTION TWO: Proposal Outline - Final Project Initiative Proposal
Write 2-3 paragraphs comparing and analyzing your city or county data with US data (or your country).
State the health issue you are choosing for your population health initiative (one – two sentences):
Explain why you chose this health issue (one - two paragraphs):
Describe your chosen population. Be specific by providing demographics to fully explain your population (provide two – three sentences to explain why these demographics are important):
List and describe three objectives you hope to accomplish with your initiative (one sentence for each objective). Use the SMART topics as a guide. (SMART – specific, measureable, actionable, reasonable, time bound)
Describe two – three activities you will use to accomplish each of these objectives (one – two sentences for each activity).
Directions: Write the activity on the line by the number and then use space underneath the number to provide specific discussion. Please be specific in describing the activity. For example, if you want to have a 10 K race, state details about the event.
Three Activities for Objective 1
Three Activities for Objective 2
Three Activities for Objective 3