World Health Organization s4

24-03-03

World Health Organization

Health impact assessment (HIA) information collection form

The World Health Organization is developing a health impact assessment gateway web site (http://www.who.int/hia) as a component of the main WHO web site, to provide access to information and experiences on HIA and its use in policy making for a global audience.

We are looking for examples of completed HIAs, tools and methods, analysis of their use in policy decisions, and any other documents relevant to HIA.

You and your organization are asked to assist us by providing such documents. This can be in the form of an electronic file (PDF or other) – the preferred option, webaddress (URL), a hard-copy text, or a focal person we can contact to fill in this form. Please complete the details below for each document you have:

Your name and contact details (email, address, and phone): ______

______

Title of the work: ______

Author (s): ______

I have emailed the Word/PDF file to Yes / No

Web address (URL) of the contribution :______

Reference: ______

WHO will acknowledge authorship of documents alongside the displayed document on the WHO web site. Unless stated otherwise in a separate letter, completion of this form constitutes the copyright owner’s agreement that WHO can use the documents and contact details of author(s) in the following manner:

· Be displayed on the WHO web site;

· Be included in CD-ROM and summary paper versions of the WHO web site, aimed at distribution for those with difficulty accessing the web;

· Be used in other documentation produced by the WHO HIA programme;

· Be used by WHO for contacting the authors regarding HIA related matters.

The information provided will not be used for the promotion of commercial products or services.

Please indicate by marking the box if you do not want:

· name and contact details of author (s) to be included in a HIA contact list on the WHO web site.

· Documents and author(s) contact details to be passed to WHO Collaborating Centres for their HIA related work.

Please return this form by email to , or by fax to +41 22 791 4123, or post to Dr Carlos Dora, Health Impact Assessment Programme, World Health Organization, Avenue Appia 20, CH-1211, Geneva 27, Switzerland.