IAM DATA COLLECTION FORM

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IAM DATA COLLECTION FORM - Short

PLEASE COMPLETE THE FORM BELOW:

(Your answers will be saved when you "submit" them at the end.)

Village

Utqiagvik

Kaktovik

Nuiqsut

Point Hope

Point Lay

Wainwright

Gambell

Atqasuk

Anaktuvuk Pass

Savoonga

Choose one

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Listening Way Leader (LWL) number (00)

Who is Reporting, if not LWL - Name and/or Description (example: adult female)

What type of issue would you categorize this as (please select from the list below)

Health: including physical, mental, and emotional): disease, injury, bipolar, PTSD, suicide, alcohol and drug abuse, etc,

Infrastructure: roads, bridges, utilities (water, fuel, communications, etc.) schools, hospitals.

Quality of Life: public safety; services and activities for youth, adults, and elders; cultural and recreational activities, adequate recreational activities, adequate jobs, safe workplaces, worship, and shopping facilities, expanded reasons and facilities for community gatherings)

Spiritual: access to churches, pastor, clergy and village elders

Communication/Interaction: (effort to have local gatherings and events that bring the community together)

Who is affected? (check all that apply)

Personal

Family

Community

Youth

Adults

Senior

Briefly describe the issue, concern or opportunity below

Briefly describe if you have a suggestion for how to help or resolve the issue

Who should be involved in solution?

Who should be informed?

Who should be informed - contact information

Please provide additional information you deem helpful.

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