Virtual Coach: HealthMatters Program Application

Virtual Coach: HealthMatters Program Application

IMPORTANT: ONE Application per Organization only.

Application deadline is October 2nd, 2020. Approved Organizations will be contacted by October 9th, 2020.

Up to 50 organizations may participate. These include, but are not limited to the following:
1. Community based organizations who provide services to people with intellectual and developmental disabilities (day and residential programs)
2. Project SEARCH sites
3. Schools
4. Managed Care Organizations

This program is one (1) year long and requires the following commitments:

1. Attend one 3-hour webinar (minimum 3 support staff participants) - see application instructions for scheduled webinar dates.
2. Run at least one Virtual Coach: 12-week HealthMatters Program.
3. Complete before and after survey and participate in monthly updates.

www.HealthMattersProgram.org
Department of Disability and Human Development, University of Illinois at Chicago
UIC IRB Protocol # 2020-0754
Award Number: 2020COVID-01 CCTS Pilot Translational and Clinical Studies Program 2020.

Organization Name *
Type of Organization *

Type of Organization DD Service Provider Project SEARCH site Managed Care Organization Other Other
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Executive Director Name * First Last
Executive Director Email *
How many employees does your Organization have? *
Does your Organization have a Wellness Committee? *

Does your Organization have a Wellness Committee? Yes No
Team Coordinator (This is the main contact for the Virtual Coach: HealthMatters Program) * First Last
Team Coordinator Job Title *
Team Coordinator Email (Confirmation email will be sent to this address) *
Team Coordinator Phone Number * - ### - ### ####
Please list at least TWO additional Staff Team Members including their First and Last Name, Job Title, and email address. The team members will also attend the webinar training. *
Would you like us to add you to our HealthMatters Alerts Listserv? We NEVER sell or give away your email and we will never spam you. All provided emails will be added. *

Would you like us to add you to our HealthMatters Alerts Listserv? We NEVER sell or give away your email and we will never spam you. All provided emails will be added. Yes No

How familiar are you with theHealthMatters Program? *
	Yes	No
Have you attended HealthMatters Program Train-the-Trainer Certified Instructor Workshop before?	Yes	No
Have you ever implemented a 12-week HealthMatters Program for people with IDD?	Yes	No
Does your organization have an active 12-week HealthMatters Program?	Yes	No

How many participants with intellectual disabilities will participate in a 12-week HealthMatters Program (this is just an estimate)? *
1. Please describe how you see Virtual Coach: HealthMatters Program as part of your organizational Strategic Plan. What potential challenges do you foresee and what are some methods that you might implement in order to mitigate these barriers? What supports can we provide to help you be successful? *
2. Describe your current health promotion programming (please include virtual activities as well) and any relevant partnerships. Include information about what is working and what aspects need improvement. You might also describe how you have historically allocated or leveraged resources to connect with community opportunities outside the organization. *
3. Please outline your plan for who will be part of your Virtual Coach: HealthMatters Program Team, including specifically naming the staff who will become Certified Virtual Instructors, including the Team Coordinator. Please note any stellar achievements of the team members as relates to this work. *
Are you planning to bill for this activity? *

Are you planning to bill for this activity? Yes No Unsure
Do you have any questions or additional comments?