[Directions: Insert information for our COIN Collaborations in the following template. Fill in our agency name and representative where indicated.]
Questionnaire Template/Phone Script
Hello, my name is _______________________ with _______________________________.
We are currently working in the community to identify and reach at-risk populations to improve day-to-day communication and to be prepared to reach them in an emergency. I’ve done some searching and I understand that your organization serves___________________________________ in __________________. 
We want to improve our ability to communicate with at-risk populations in the community. Would someone in your organization be willing to assist us by answering some questions about your organization, the population it serves, and its communication capabilities?
Sample Questions:
1.	What populations does your organization serve (please list):
	
2.	What are your organization’s outreach capabilities? 
	
3.	How many do you serve?
	
4.	Where is your organization located? 
	
5.	What geographic areas does your organization serve?  
	
6.	How do you communicate with or reach the populations you serve? 
U.S. Mail address list
Phone or fax list
E-mail listserv
Other
	
Which ones?

7.	Do you target messaging specifically for different populations? 
	
8.	Would you consider your organization to be an overarching organization? 
Yes  	No 

9.	Does your organization have member organizations?
Yes  	No 
	
	If yes, who are they? 	
	
	If no, how does your organization fit in your community’s communication chain?

If the phone conversation goes well and the organization representative seems to fit with your goals and objectives:
•	Ask them for his/her contact information
	
•	Try and schedule a meeting to talk more in depth about future and ongoing formal or informal collaboration.  
Meeting Scheduled:   Yes  	   No 
When and Where?