PolicyMap Request Form Salutation*Dr.Mr.Ms.Mrs.None1. Name* First Last 2. Title* 3. Institution* 4. Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 5. Description of your organzation/institution*UConn HealthUCONNState AgencyNon-profitFor-profit companyOther Higher educationIndependent ConsultantMunicipalSchool districtOtherSelect one5a. If choose other- please describe* 6. Email* 7. Phone*8. Summarize the goals of your organization and department.*9. How many people will be accessing PolicyMap?*10. For what purpose does your organization plan to utilize PolicyMap?*Formal analysisPresentationPublicationCommunity ConnectionHealth ServicesOtherSee Attachment10a. Other* Will PolicyMap be used toward efforts in advancing health equity?* Yes No Unsure PhoneThis field is for validation purposes and should be left unchanged.