PHASE 1:  DEFINING AT-RISK POPULATIONS
STEP 1 – Collect Population Information and Data:
Check the online information resources we use most for collection of data:
☐	www.census.gov	
☐	http://factfinder2.census.gov/	
☐	www.censusscope.org	
☐	www.abag.ca.gov/abag/other_gov/rcg.html	
☐	www.nsgic.org	
☐	www.naco.org	
☐	Other (list)	Click here to enter text.	

STEP 2 – Estimate the Number of People in Our At-risk Populations
☐	Economic Disadvantaged	Estimated Number	
	Total estimated number of people in this category:	  	
				
	☐	People at or near the poverty level	  	
		Additional Notes:	  	
	
	☐	Unemployed people	  	
		Additional Notes:	  	
	
	☐	Working poor with limited resources	  	
		Additional Notes:	  	
	
	☐	Medicaid recipients	  	
		Additional Notes:	  	
	
	☐	Single mothers and sole caregivers	  	
		Additional Notes:	  	
	
	☐	Low wage workers in multiple jobs	  	
		Additional Notes:	  	
	
	☐	Ethnic and racial minorities	  	
		Additional Notes:	  	
	
	☐	Other 	Enter description	  	
		Additional Notes:	  	

	
☐	Language and Literacy	Estimated Number	
	Total estimated number of people in this category:	  	
				
	☐	Limited English proficiency, or low literacy	  	
		Additional Notes:	  	
	
	☐	Non-English-speaking groups	  	
		Additional Notes:	  	
	
	☐	Spanish language speakers	  	
		Additional Notes:	  	
	
	☐	Asian and Pacific Island speakers (Chinese, Korean, Japanese, Vietnamese, Hmong, Khmer, Lao, Thai, Tagalog, Dravidian, Polynesian, and Micronesian languages)	  	
		Additional Notes:	  	
	
	☐	All other language speakers	  	
		Additional Notes:	  	
	
	☐	Sign Language/ American Sign Language(ASL)	  	
		Additional Notes:	  	
	
	☐	Illegal/undocumented immigrants	  	
		Additional Notes:	  	
	
	☐	Immigrants or refugees	  	
		Additional Notes:	  	
	
	☐	Other 	Enter description	  	
		Additional Notes:	  	

☐	Medical Issues and Disabilities	Estimated Number	
	Total estimated number of people in this category:	  	
				
	☐	Blind and/or visually impaired	  	
		Additional Notes:	  	
	
	☐	Deaf and/or hard of hearing	  	
		Additional Notes:	  	
	
	☐	Mobility-impaired	  	
		Additional Notes:	  	
	
	☐	Medically and/or Electrically Dependent (life support or medical equipment)	  	
		Additional Notes:	  	

	
	☐	Chronic Disease/Infirm	  	
		Additional Notes:	  	
	
	☐	Diagnosed with HIV/AIDS	  	
		Additional Notes:	  	
	
	☐	Immune-compromised	  	
		Additional Notes:	  	
	
	☐	Drug and/or alcohol-dependent (perhaps not in treatment)	  	
		Additional Notes:	  	
	
	☐	Diagnosed with mental illness (in treatment)	  	
		Additional Notes:	  	
	
	☐	Chronic pain patients	  	
		Additional Notes:	  	
	
	☐	Non-Hospitalized Patients	  	
	
	☐	Require renal dialysis	  	
	
	☐	Require supplemental oxygen	  	
	
	☐	Require daily medication	  	
	
	☐	People receiving chemotherapy	  	
	
	☐	Clinically-depressed patients	  	
	
	☐	Stroke patients	  	
		Additional Notes:	  	
	
	☐	Pregnant women	  	
		Additional Notes:	  	
	
	☐	People recuperating at home (e.g., from acute injuries or surgeries)	  	
		Additional Notes:	  	
	
	☐	People who need eyeglasses to be able to function capably	  	
		Additional Notes:	  	
	
	☐	Other 	Enter description	  	
		Additional Notes:	  	

	

☐	Isolation (Cultural, Geographic, or Social	Estimated Number	
	Total estimated number of people in this category:	  	
				
	☐	Homebound elderly	  	
		Additional Notes:	  	
	
	☐	Homeless people	  	
		Additional Notes:	  	
	
	☐	People living alone	  	
		Additional Notes:	  	
	
	☐	Sole caregivers	  	
		Additional Notes:	  	
	
	☐	Single individuals without extended family	  	
		Additional Notes:	  	
	
	☐	Low-income people	  	
		Additional Notes:	  	
	
	☐	People living in remote or rural areas	  	
		Additional Notes:	  	
	
	☐	People living in shelters	  	
		Additional Notes:	  	
	
	☐	Undocumented immigrants	  	
		Additional Notes:	  	
	
	☐	People dependent on public transportation	  	
		Additional Notes:	  	
	
	☐	Rural and urban ethnic groups	  	
		Additional Notes:	  	
	
	☐	Religious communities (that might choose to be isolated from the general population, e.g., Mennonite or Amish)	  	
		Additional Notes:	  	
	
	☐	Seasonal or migrant workers	  	
		Additional Notes:	  	
	
	☐	Commuters	  	
		Additional Notes:	  	
	
	☐	People already displaced by a disaster	  	
		Additional Notes:	  	
	
	☐	School populations	  	
		Additional Notes:	  	
	
	☐	Tourists and travelers	  	
		Additional Notes:	  	
	
	☐	People isolated by recreational activities (campers, hikers)	  	
		Additional Notes:	  	
	
	☐	Truckers, pilots, rail workers, or other transportation workers in the area	  	
		Additional Notes:	  	
	
	☐	Military personnel	  	
		Additional Notes:	  	
	
	☐	Campers and/or staff at seasonal residential camps	  	
		Additional Notes:	  	
	
	☐	Other:	  	
		Additional Notes:	  	

☐	Age	Estimated Number	
	Total estimated number of people in this category:	  	
				
	☐	Elderly (with limited strength, but not disabled)	  	
		Additional Notes:	  	
	
	☐	People classified as Senior Citizens	  	
		Additional Notes:	  	
	
	☐	Children under age 18	  	
		Additional Notes:	  	
	
	☐	Infants	  	
		Additional Notes:	  	
	
	☐	Mothers with newborns	  	
		Additional Notes:	  	
	
	☐	Families with children that have health care needs	  	
		Additional Notes:	  	
	
	☐	Grandparents who are guardians or caretakers of children	  	
		Additional Notes:	  	
	
	☐	Other:	  	
		Additional Notes:	  	

STEP 3 – Overarching Organizations or Agencies and Their Key Contacts for Each Group Identified:
List some of the main overarching organizations or agencies and their key contacts for each group identified. If this list is long, utilize the COIN Key Contacts spreadsheet template.
 
Economic Disadvantaged
Organization	Key Contact	Address	Phone	

				

Language and Literacy
Organization	Key Contact	Address	Phone	

				

Medical Issues and Disability
Organization	Key Contact	Address	Phone	

				

Isolation (Cultural, Geographic, or Social)
Organization	Key Contact	Address	Phone	

				

Age
Organization	Key Contact	Address	Phone	

				
	
Additional Notes:

STEP 4 – Facilitate Discussions with Key Contacts:

Economic Disadvantage
Key Contact	Address / Phone	Date	Issue	

				

	
Language and Literacy
Key Contact	Address / Phone	Date	Issue	

				

	
Medical Issues and Disability
Key Contact	Address / Phone	Date	Issue	

				

	
Isolation (Cultural, Geographic, or Social)
Key Contact	Address / Phone	Date	Issue	

				

	
Age
Key Contact	Address / Phone	Date	Issue	

				

	
Additional Notes:

STEP 5 – Staying In Touch:
Economic Disadvantage
Key Contact	Address / Phone /Fax	Next Callback Scheduled	

			

	
Language and Literacy
Key Contact	Address / Phone /Fax	Next Callback Scheduled	

			

Medical Issues and Disability
Key Contact	Address / Phone /Fax	Next Callback Scheduled	

			

	
Isolation (Cultural, Geographic, or Social)
Key Contact	Address / Phone /Fax	Next Callback Scheduled	

			

		
Age
Key Contact	Address / Phone /Fax	Next Callback Scheduled	

			

	
	Additional Notes:

PHASE 2:  LOCATING AT-RISK POPULATIONS

STEP 1 – Assess Existing Processes to Locate At-risk Populations:

Group Identified	Existing Efforts to Map Locations	

		

Additional Notes:

STEP 2 – Choose Digital Mapping or Alternate Methods of Mapping:

Digital Mapping Resource Used	Website Address or Location	

		
		
[Enter any digital map or other map links information here)

Additional Notes:

STEP 3 – Locate and Map Gathering Places for the Identified At-risk Groups:

At-risk Group	Address, Location Identified, or Other Location Information	

		
		
 [Enter any digital map or other map links information here)

Additional Notes:

STEP 4 – Locate and Map Trusted Sources for the Identified At-risk Groups:

At-risk Group	Trusted Source Name	Address and Phone	

			
			
 [Enter any digital map or other map links information here)

Additional Notes:

STEP 5 – Facilitate Discussions with Representatives from Community Organizations Associated with At-risk Populations

At-risk Group	Key Contact	Address / Phone /Fax	Meeting
 Scheduled	

	

			

	

			
	
Additional Notes:

STEP 6 – Expand your COIN to Include Service Providers, Businesses, and Others Who Work with At-risk Populations

At-risk Group	Business and Principal Contact	Address / Phone /Fax	Meeting or Call
 Scheduled	

	

			

Additional Notes:

PHASE 3:  REACHING AT-RISK POPULATIONS
STEP 1 – Survey Agencies and Organizations to Learn About Their Successes and Failures

Agency	Principal Contact	Address / Phone /Fax	Meeting or Call
 Scheduled	

Agency Program Discussed and Outcome	

	
Agency	Principal Contact	Address / Phone /Fax	Meeting or Call
 Scheduled	

Agency Program Discussed and Outcome	

	
Agency	Principal Contact	Address / Phone /Fax	Meeting or Call
 Scheduled	

Agency Program Discussed and Outcome	

	

Additional Notes:

STEP 2 – Conduct Focus Groups or Community Roundtables

At-risk Population	Community Contact	Address / Phone /Fax	Meeting or Call
 Scheduled	

Roundtable Discussion Subject and Notes	

	

At-risk Population	Community Contact	Address / Phone /Fax	Meeting or Call
 Scheduled	

Roundtable Discussion Subject and Notes	

	
At-risk Population	Community Contact	Address / Phone /Fax	Meeting or Call
 Scheduled	

Roundtable Discussion Subject and Notes	

	

Additional Notes:

STEP 3 – Analyze Data Gathered from the Surveys, Focus Groups, and Previous Assessment Efforts

At-risk Population	Date of Discussion	Subject	Notes	

				

				

				

				

Additional Notes:

STEP 4 – Collaborate with Community Organizations

At-risk Population	Collaborative 
Effort Planned	Key Contact Info	Date	

				

				

Additional Notes:

STEP 5 – Identify Appropriate, Trusted Messengers

At-risk Population	Messenger
Name	Address, Phone, and Email	

			

			

Additional Notes: