Promenpol Sign-Up Form

/ Promoting and Protecting Mental Health – Supporting Policy through Integration ofResearch, Current Approaches and Practices.
Contract No: Contract No.: 44406

ProMenPol “Expression of Interest”

Please tick/fill in the appropriate boxes. Once you have finished filling in the form, please save it on your computer and send it by e-mail to:

Rena Hohenstein: andGert Lang

Your last name, first name:,

A. Organisational data:

1. Full name of your organisation:

2. Department or Division:

3. Address and Postal Code:

4. Town and Country:

5. Tel.:

6. Fax:

7. Email:

8. Website:

B. Conference participation:

I would like to participate in the ProMenPol conference on June 19th and 20th2008 in Berlin:

Yes

If yes, please tell us which workshop you are most interested in:

Education

Workplace

Older people

C. Pilot Sites:

I want to voluntarily take part in the ProMenPol Pilot Sites:

Yes

I am interested, but not sure, yet.

Today’s Date:

Only if you already know, that you will take part in the ProMenPol Pilot Sites, please also answer the following questions:

Contact person for Pilot sites in your organisation (Last name, first name): ,

C.1 In which type of setting will the pilot take place?

A school or university

A workplace

A residence for older people

C.2Which type of pilot site would you like to carry out?(only tick one)

ProMenPol Pilot Site TYP 1:

ProMenPol Pilot Site TYP 2:

Yes, I agree to test and assess the ProMenPol Online Database on mental health promotion tools at and document the toolset’s utility, functionality and practicability for my organisation. I also agree to choose one (or more) tools from the Online Database and implement them in my organisation, and to document the implementation process. (Documentation formats will be sent to you when you start the pilot.)

ProMenPol Pilot Site TYP 3:

Yes, I am already actively implementing mental health promotion tools in my organisation and I want to report on a tool already in use by my organisation in the course of an existing initiative and I will report on its utility and practicality.

C.3When would you like to start and end your pilot?(Reporting will be possible between June 2008 and September 2009)

Insert starting date [mm:yyyy]:

Insert end date [mm:yyyy]:

I agree to send all formats of the documentation process back to by the end of my pilot. All data will be handled confidentially by the ProMenPol project.