Public Health Corps Site Application

Please refer to the Guide to Partnering for more information about the program.

Site Name: *

Minnesota Public Health Corps was created to support and grow the governmental public health system. We will prioritize partnering primarily with governmental public health agencies and community health boards for the 2024-25 program year. We will also consider awarding non-governmental public health organizations that are adjacent to the governmental public health sector and that help facilitate governmental public health initiatives across the state, subject to available funding. Such initiatives should be population-based as opposed to direct service in nature and in direct support of governmental public health departments or their activities.

Restrictions or additional policies may also apply for AmeriCorps service at sites that are faith-based/religious or for-profit entities.

Please indicate whether the criteria below apply to your site (check all that apply).

Governmental public health entity (e.g. health department)

Community health board

Faith-Based/Religious

For-Profit

Street Address *

Address Line 2

City *

State *

Zip Code *

Minnesota County *

County: *

Organization Information & Community Need

Briefly describe your organization's mission and vision. *

0/300 words

Help us better understand the population and community that the AmeriCorps member(s) will be serving through your organization. Please include information such as geographic reach, participant demographics (race, age, etc.), community need, and/or specific populations served. *

0/300 words

Director Information

First Name *

Last Name *

Position Title *

Email Address *

Phone Number *

Site Supervisor Information

All AmeriCorps programs require a Site Supervisor to provide onsite support and supervision for each member placed. If you do not know who that is at this moment, please select “designate at a later time” and a staff member will work with you to identify this person. Otherwise, select "Enter Site Supervisor Info" and please fill in the information below.

Designate a Site Supervisor: *

Enter Site Supervisor Information

Designate at a later time

First Name *

Last Name *

Position Title *

Email Address *

Phone Number *

Recruitment Contact Information

Ampact staff lead and facilitate the interview and selection process for AmeriCorps members. Partner organizations play an essential and active role in member recruitment by collaborating with Ampact staff to provide referrals and recruit prospective AmeriCorps members from their community and networks.

Please identify a recruitment contact who will lead recruitment efforts at your site and serve as a point of contact for Ampact staff for recruitment-related communication and meetings.

Who will be your Recruitment Contact? *

Same as Principal/Director

Same as Site Supervisor

Someone Else

First Name *

Last Name *

Position Title *

Email Address *

Phone Number *

In 3 sentences or less, what are you looking for in an AmeriCorps member? If you are referring a particular candidate for the position, please list their name and contact information here. (300 word limit) *

0/300 words

AmeriCorps Member Request

AmeriCorps members with Public Health Corps are referred to as Public Health Project Coordinators. Please consider the items below when determining your member request for the 2024-25 program year. If you have any questions related to your member request, please contact sites@ampact.us.

Need and variety of projects and activities
Site schedule and space availability
Availability and capacity of the Site Supervisor (we estimate that Site Supervisors designate 6-9 hours of support per member per month)

Indicate the total number of Public Health Project Coordinators requested by your organization: *

Indicate the commitment levels of Public Health Project Coordinators requested by your organization. We consider organizational requests as well as the availability of the candidate when placing members. *

Full-time (40 hours/week)

Part-time (25 hours/week)

We are planning to hire a limited number of AmeriCorps members to start their service term in July 2024 before our larger Public Health Corps AmeriCorps member cohort begins. Due to funding restrictions, this must be an AmeriCorps member who did not serve in the 2023-2024 program year. Is your site interested in and able to host AmeriCorps members beginning in July? *

Yes

No

Public Health Project Coordinators provide capacity building services to their sites. Please indicate the public health priority area(s) for which you are requesting Public Health Corps member(s) to support below. For the public health priority areas listed in each row, indicate the capacity building domain(s) in each column that you anticipate the member(s) supporting. If you do not anticipate member(s) supporting a particular public health priority area, please select "N/A" in the righthand column for that row.

The information collected here helps Public Health Corps understand how your site envisions AmeriCorps member service enhancing your capacity. This informs our site selection and member placement processes, assists us in creating member training plains, and also provides valuable insights for members to develop effective service plans.

For complete definitions and examples of each capacity building domain and public health priority area, please refer to this Public Health Corps Definitions and Examples document. *

	Community Engagement, Communication, and Outreach	Data Collection, Research, and Analysis	Process Improvement	Volunteer Management and Mobilization	Workforce Development	Coordination of Site-Specific Projects Related to the Needs of the Community and Sector	N/A
Communicable Disease Control	Community Engagement, Communication, and Outreach	Data Collection, Research, and Analysis	Process Improvement	Volunteer Management and Mobilization	Workforce Development	Coordination of Site-Specific Projects Related to the Needs of the Community and Sector	N/A
Chronic Disease and Injury Prevention	Community Engagement, Communication, and Outreach	Data Collection, Research, and Analysis	Process Improvement	Volunteer Management and Mobilization	Workforce Development	Coordination of Site-Specific Projects Related to the Needs of the Community and Sector	N/A
Environmental Public Health	Community Engagement, Communication, and Outreach	Data Collection, Research, and Analysis	Process Improvement	Volunteer Management and Mobilization	Workforce Development	Coordination of Site-Specific Projects Related to the Needs of the Community and Sector	N/A
Maternal, Child, and Family Health	Community Engagement, Communication, and Outreach	Data Collection, Research, and Analysis	Process Improvement	Volunteer Management and Mobilization	Workforce Development	Coordination of Site-Specific Projects Related to the Needs of the Community and Sector	N/A
Access to & Linkage with Care	Community Engagement, Communication, and Outreach	Data Collection, Research, and Analysis	Process Improvement	Volunteer Management and Mobilization	Workforce Development	Coordination of Site-Specific Projects Related to the Needs of the Community and Sector	N/A
Assessment and Surveillance	Community Engagement, Communication, and Outreach	Data Collection, Research, and Analysis	Process Improvement	Volunteer Management and Mobilization	Workforce Development	Coordination of Site-Specific Projects Related to the Needs of the Community and Sector	N/A
Community Partnership Development	Community Engagement, Communication, and Outreach	Data Collection, Research, and Analysis	Process Improvement	Volunteer Management and Mobilization	Workforce Development	Coordination of Site-Specific Projects Related to the Needs of the Community and Sector	N/A
Equity	Community Engagement, Communication, and Outreach	Data Collection, Research, and Analysis	Process Improvement	Volunteer Management and Mobilization	Workforce Development	Coordination of Site-Specific Projects Related to the Needs of the Community and Sector	N/A
Organizational Competencies	Community Engagement, Communication, and Outreach	Data Collection, Research, and Analysis	Process Improvement	Volunteer Management and Mobilization	Workforce Development	Coordination of Site-Specific Projects Related to the Needs of the Community and Sector	N/A
Policy Development and Support	Community Engagement, Communication, and Outreach	Data Collection, Research, and Analysis	Process Improvement	Volunteer Management and Mobilization	Workforce Development	Coordination of Site-Specific Projects Related to the Needs of the Community and Sector	N/A
Accountability and Performance Management	Community Engagement, Communication, and Outreach	Data Collection, Research, and Analysis	Process Improvement	Volunteer Management and Mobilization	Workforce Development	Coordination of Site-Specific Projects Related to the Needs of the Community and Sector	N/A
Emergency Preparedness and Response	Community Engagement, Communication, and Outreach	Data Collection, Research, and Analysis	Process Improvement	Volunteer Management and Mobilization	Workforce Development	Coordination of Site-Specific Projects Related to the Needs of the Community and Sector	N/A
Communications	Community Engagement, Communication, and Outreach	Data Collection, Research, and Analysis	Process Improvement	Volunteer Management and Mobilization	Workforce Development	Coordination of Site-Specific Projects Related to the Needs of the Community and Sector	N/A

Please describe the activities the requested AmeriCorps member(s) will perform with your organization. How will AmeriCorps service build the capacity of, but NOT replace or duplicate, the work of existing staff? *

0/300 words

AmeriCorps policy requires that AmeriCorps members serve at a physical site location, even if service activities are delivered virtually. Does your site have a physical location for AmeriCorps members to conduct their service? *

Yes

No

Sites must provide Public Health Corps members access to a computer/device with high-speed internet beginning on their first day of service to complete training and other program requirements. How will your organization ensure this expectation is met? Do you have any concerns about your organization's ability to meet this expectation due to the availability of devices, organization/agency policy, or other factors? *

0/300 words

Will AmeriCorps members at your organization do any driving as part of their service (i.e. between site locations, within the community)? Members are not allowed to drive clients, children, or hazardous products (chemicals, power tools, etc.). Members under the age of 18 are not allowed to drive as part of their service. *

All AmeriCorps members expected or required to drive their own cars or company-provided vehicles are required to complete a motor vehicle check for Ampact that must be approved before they can begin driving as part of their service.

Are AmeriCorps members at your organization expected to drive an organization-provided vehicle as part of their service? *

Please list any requirements your organization has for AmeriCorps members placed at your site. Please include as much detail as possible so Ampact staff can inform candidates of site-based requirements during the interview and selection process. *

0/300 words

Please list any other considerations or preferences related to your AmeriCorps member request.

0/300 words

Site Agreement Information

All Ampact site partners must sign a site agreement outlining the partnership between the site and the program. Our site agreement requires the signature of someone who is authorized to enter into an agreement on behalf of your site or district/agency.

Click here if the contact to sign the Public Health Corps Site Agreement is someone other than the Director.

First Name *

Last Name *

Email Address *

Phone Number *

Position Title *

Review & Submit

Please provide the information of the person completing this site application below.

Review the form before clicking the "Submit" button below to submit this application. The Principal/Director listed above will receive a copy of this application via email.

First Name *

Last Name *

Phone Number *

Email Address *

Position Title *