PATH IMPLEMENTATION PLAN Please Print or Type I. CONTACT INFORMATION Date: Organization Name: Program(s) to be implemented: all that apply) PATH (Chronic Disease Self-Management Program) Diabetes PATH (Diabetes Self-Management Program) Chronic Pain PATH Tomando Control de Su Salud (TCDSS) Cancer: Surviving and Thriving Upper management (has authority to agree to Key contact/Organizational liaison implementation) Name: Name: Position or Title: Position or Title: Email: Phone: Mailing address: Physical address (if different from mailing): City: City: State: State: ZIP code: ZIP code: Website: Phone: II. OVERVIEW OF Briefly describe how you will implement this /these program(s) (30 words or less) List counties where programs will be implemented: Will you be using staff, volunteers or both to implement this plan? III. If you don’t have an Organizational Liaison, when do you plan to have one in place? Will your program(s) be available to the community/public or will they be closed?
PATH Please Print or Type I. CONTACT INFORMATION Organization Name: Date: Program(s) to be implemented: all that apply) PATH (Chronic Disease Self-Management Program) Diabetes PATH (Diabetes Self-Management Program) Chronic Pain PATH Tomando Control de Su Salud (TCDSS) Cancer: Surviving and Thriving Key contact/Organizational liaison Name: Position or Title: Phone: Upper management (has authority to agree to implementation) Name: Position or Title: Email: Mailing address: City: State: ZIP code: Physical address (if different from mailing): City: State: ZIP code: Website: Phone: II. OVERVIEW OF PLAN Briefly describe how you will implement this /these program(s) (30 words or less) List counties where programs will be implemented: Will you be using staff, volunteers or both to implement this plan? III. IMPLEMENTATION If you don’t have an Organizational Liaison, when do you plan to have one in place? Will your program(s) be available to the community/public or will they be closed?
Implementation-Plan_3-15-16.docx