Intake Assessment

Contact Information

Date:

Contact Name: *

Lead Staff:

(if different from contact name)

Organization Name: *

Contact Title:

Contact E-Mail Address: *

Email of person entering this survey: *

State/Province:

City: *

Zip:

Phone Number: *

Website:

Street Address:

Organizational Planning and Financial Support

Do you have the following (check all that apply):

Annual Budget

Annual Work Plan

Strategic Plan

Fundraising Plan

Board Development Plan

Information Technology (IT) Plan

Public Outreach Plan/Communications

Watershed Plan or other Vision Statement for your Watershed

Water Quality Monitoring Assessment Plan

Funding Sources (as % of Income)

Dues paid by members: %

Individual donors, beyond dues: %

Events: %

Private foundation grants: %

State Government (not 319): %

Environmental Protection Agency 319 funding: %

Other governmental funding (municipal, other Federal): %

Corporate or business sponsors: %

All other sources (sales, fees, etc...): %

Evaluation of Services

In the last two years, what types of technical assistance, training, or outside help, has your group received, and how helpful were they?: *

	not helpful	somewhat helpful	helpful	very helpful
Trainer/facilitator came to our group meeting to lead planning session, training, or provide other assistance:
Member(s) of my group attended training workshop(s) or conferences:
I received one-on-one consulting and/or coaching support:
I received assistance from online network, written or online materials:

How did these services help you achieve your environmental and/or organizational outcomes: *

How could we improve training and support your organization: *

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