Express CHNA™ Proposal Request Form

Thank you for your interest in the Express CHNA™ a rapid, PHAB-aligned, and MAPP 2.0-compliant community health needs assessment designed for departments working under tight timelines and funding constraints. Please complete this brief form so we can tailor your proposal and help you move forward with confidence.

Express CHNA™ Proposal Request Form

First name

Last name

Title/Role

Health Department

Phone

Project Timeline

Preferred Kickoff Date

Month

Day

Year

Required Final Report Delivery Date (minimum 45 days after kickoff)

Month

Day

Year

Community Overview

County/Service Area

Population Served

Have you completed a CHNA in the last 3 years?

Yes

Top 2–3 health priorities or areas of concern

Optional Add-On Services

Check all that apply. Residential surveys extend the timeline by 30 days

Residential Survey (1,000 responses) $3,500

Residential Survey (2,000 responses) $6,000

Public Presentation of Findings $2,000

Executive Infographic Summary $750

Additional Stakeholder Interviews (5) $1,500

Your Commitments

To support timely delivery, your team agrees to:

Assign a project coordinator
Provide background materials and 20 partner contacts within 5 business days
Help schedule 10 stakeholder interviews
Distribute electronic partner survey
Review draft within 3 business days