This form can be copied for use in completing Step Five: Developing a Plan.
At-Risk Linkage Team Action Plan Team Name ___________________________________________________________________ Member Information Complete for each team member: Team Member #1 (Chair/Contact Person) Name_________________________________________________________________________ Position_______________________________________________________________________ Agency________________________________________________________________________ Address_______________________________________________________________________ ____________________________________________County____________________________ Telephone ______/__________________ Team Member #2 Name_________________________________________________________________________ Position_______________________________________________________________________ Agency________________________________________________________________________ Address_______________________________________________________________________ ____________________________________________County____________________________ Telephone ______/__________________ Team Member #3 Name_________________________________________________________________________ Position_______________________________________________________________________ Agency________________________________________________________________________ Address_______________________________________________________________________ ____________________________________________County____________________________ Telephone ______/__________________ Team Member #4 Name_____-____________________________________________________________________ Position_______________________________________________________________________ Agency___-_____________________________________________________________________ Address_______________________________________________________________________ ____________________________________________County____________________________ Telephone ______/__________________ Team Member #5 Name____-_____________________________________________________________________ Position_______________________________________________________________________ Agency__-______________________________________________________________________ Address_______________________________________________________________________ ____________________________________________County____________________________ Telephone ______/__________________ Team Member #6 Name____-_____________________________________________________________________ Position_______________________________________________________________________ Agency__-______________________________________________________________________ Address_______________________________________________________________________ ____________________________________________County____________________________ Telephone ______/__________________ Team Member #7 Name_________________________________________________________________________ Position_______________________________________________________________________ Agency________________________________________________________________________ Address_______________________________________________________________________ ____________________________________________County____________________________ Telephone ______/__________________ Team Member #8 Name_________________________________________________________________________ Position_______________________________________________________________________ Agency________________________________________________________________________ Address_______________________________________________________________________ ____________________________________________County____________________________ Telephone ______/__________________ Team Member #9 Name_________________________________________________________________________ Position_______________________________________________________________________ Agency________________________________________________________________________ Address_______________________________________________________________________ ____________________________________________County____________________________ Telephone ______/__________________ Action Plan I. List the priority needs of your area _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ II. Sources of needs assessment information _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ III. Define target audience _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ IV. Purpose/Goal _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ V. Objectives 1.0_____________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 2.0_____________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 3.0_____________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 4.0_____________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 5.0_____________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ VI. Implementation plan Objective 1.0: _________________________________________________________ Anticipated Persons(s) Completion Procedure/Activity Responsible Date 1.1 ____________________________________ ________________ ___________ ____________________________________ 1.2 ____________________________________ ________________ ___________ ____________________________________ 1.3 ____________________________________ ________________ ___________ ____________________________________ 1.4 ____________________________________ ________________ ___________ ____________________________________ 1.5 ____________________________________ ________________ ___________ ____________________________________ 1.6 ____________________________________ ________________ ___________ ____________________________________ 1.7 ____________________________________ ________________ ___________ ____________________________________ 1.8 ____________________________________ ________________ ___________ ____________________________________ 1.9 ____________________________________ ________________ ___________ ____________________________________ 1.10 ____________________________________ ________________ ___________ ____________________________________ 1.11 ____________________________________ ________________ ___________ ____________________________________ 1.12 ____________________________________ ________________ ___________ ____________________________________ Objective 2.0: _________________________________________________________ Anticipated Persons(s) Completion Procedure/Activity Responsible Date 2.1 ____________________________________ ________________ ___________ ____________________________________ 2.2 ____________________________________ ________________ ___________ ____________________________________ 2.3 ____________________________________ ________________ ___________ ____________________________________ 2.4 ____________________________________ ________________ ___________ ____________________________________ 2.5 ____________________________________ ________________ ___________ ____________________________________ 2.6 ____________________________________ ________________ ___________ ____________________________________ 2.7 ____________________________________ ________________ ___________ ____________________________________ 2.8 ____________________________________ ________________ ___________ ____________________________________ 2.9 ____________________________________ ________________ ___________ ____________________________________ 2.10 ____________________________________ ________________ ___________ ____________________________________ 2.11 ____________________________________ ________________ ___________ ____________________________________ 2.12 ____________________________________ ________________ ___________ ____________________________________ Objective 3.0: _________________________________________________________ Anticipated Persons(s) Completion Procedure/Activity Responsible Date 3.1 ____________________________________ ________________ ___________ ____________________________________ 3.2 ____________________________________ ________________ ___________ ____________________________________ 3.3 ____________________________________ ________________ ___________ ____________________________________ 3.4 ____________________________________ ________________ ___________ ____________________________________ 3.5 ____________________________________ ________________ ___________ ____________________________________ 3.6 ____________________________________ ________________ ___________ ____________________________________ 3.7 ____________________________________ ________________ ___________ ____________________________________ 3.8 ____________________________________ ________________ ___________ ____________________________________ 3.9 ____________________________________ ________________ ___________ ____________________________________ 3.10 ____________________________________ ________________ ___________ ____________________________________ 3.11 ____________________________________ ________________ ___________ ____________________________________ 3.12 ____________________________________ ________________ ___________ ____________________________________ Objective 4.0: _________________________________________________________ Anticipated Persons(s) Completion Procedure/Activity Responsible Date 4.1 ____________________________________ ________________ ___________ ____________________________________ 4.2 ____________________________________ ________________ ___________ ____________________________________ 4.3 ____________________________________ ________________ ___________ ____________________________________ 4.4 ____________________________________ ________________ ___________ ____________________________________ 4.5 ____________________________________ ________________ ___________ ____________________________________ 4.6 ____________________________________ ________________ ___________ ____________________________________ 4.7 ____________________________________ ________________ ___________ ____________________________________ 4.8 ____________________________________ ________________ ___________ ____________________________________ 4.9 ____________________________________ ________________ ___________ ____________________________________ 4.10 ____________________________________ ________________ ___________ ____________________________________ 4.11 ____________________________________ ________________ ___________ ____________________________________ 4.12 ____________________________________ ________________ ___________ ____________________________________ Objective 5.0: _________________________________________________________ Anticipated Persons(s) Completion Procedure/Activity Responsible Date 5.1 ____________________________________ ________________ ___________ ____________________________________ 5.2 ____________________________________ ________________ ___________ ____________________________________ 5.3 ____________________________________ ________________ ___________ ____________________________________ 5.4 ____________________________________ ________________ ___________ ____________________________________ 5.5 ____________________________________ ________________ ___________ ____________________________________ 5.6 ____________________________________ ________________ ___________ ____________________________________ 5.7 ____________________________________ ________________ ___________ ____________________________________ 5.8 ____________________________________ ________________ ___________ ____________________________________ 5.9 ____________________________________ ________________ ___________ ____________________________________ 5.10 ____________________________________ ________________ ___________ ____________________________________ 5.11 ____________________________________ ________________ ___________ ____________________________________ 5.12 ____________________________________ ________________ ___________ ____________________________________ VII. Evaluation Criteria _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ VIII. Products _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ IX. Dissemination Plan _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Team Signatures: #1 _________________________________________________ ___________ signature date #2 _________________________________________________ ___________ signature date #3 _________________________________________________ ___________ signature date #4 _________________________________________________ ___________ signature date #5 _________________________________________________ ___________ signature date #6 _________________________________________________ ___________ signature date #7 _________________________________________________ ___________ signature date #8 _________________________________________________ ___________ signature date #9 _________________________________________________ ___________ signature date