PolicyMap Request Form | Health Disparities Institute

Salutation*
1. Name*
First Last
2. Title*
3. Institution*
4. Address*
Street Address Address Line 2 City State ZIP Code
5. Description of your organzation/institution*
Select one
5a. 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?*
See Attachment
10a. Other*
Will PolicyMap be used toward efforts in advancing health equity?*
- Yes
- No
- Unsure
Name
This field is for validation purposes and should be left unchanged.