Updated 17-02-10
Health Promotion Request Form
Name: ___________________________
Position: _________________________________
Phone: ___________________________
Email: ___________________________________
Organisation: __________________________________________________________________
Date of request: _____________________
This form is to guide Health Promotion planning and implementation within the Wheatbelt.
It will assist you to identify local issues and work with other Health Staff Members to
tackle an issue via several planned strategies, rather than one-off events.
Using the details provided over the page, complete and send this form via fax or post to your
local Health Promotion Officer who will then contact you. You are encouraged to contact your
local Health Promotion Officer via phone and discuss this request for support and clarification.
1. Health issue/ problem
2. Who is the target
audience?
Age:
Gender:
Type of group (eg. farmers, mums, seniors, ethnicity):
3. Proposed strategies
Existing program:
(Contact Health Promotion
Officer for information on
existing programs)
4. Have you tried
New idea:
Yes
something already?
No
If ‘yes’ explain:
What barriers have you found when trying to address the issue?
5. Who else have you
already involved?
(eg. School, Shire, Bowls club)
6. What assistance are you
seeking?
(See Role of Health Promotion
Officer over page for ideas)
7. Location
8. Proposed timeline
Page 1
Population Health - Wheatbelt
Primary Health Services in the Avon and Central, Eastern, Southern and Western Wheatbelt
Wheatbelt Public Health Unit and Wheatbelt Aboriginal Health Service
Updated 17-02-10
Health Promotion Request Form – Information & Contact Details
For assistance completing this form please contact the Health Promotion Officer in your district.
Role of Health Promotion Officer:
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Help identify local priority health issues for the community, which reflect National and State
priorities.
Develop, plan, implement and evaluate health promotion programs and strategies together with
stakeholders and the community.
Support and empower both staff and community groups to develop, plan, implement, sustain
and evaluate local health promotion programs.
Organise and support educational and advocacy strategies to promote healthy behaviour.
Support state-wide health promotion campaigns when appropriate - including information about
accessing resource materials and grant applications.
Prepare draft media release and advertising and develop this skill in other staff.
Organise and/or attend relevant partnership meetings to network and ensure partnerships for
health promotion initiatives (i.e. partnerships with health services, local government, and
private and community organisations).
Provide relevant presentations, workshops, seminars and reports to raise the profile of health
promotion when requested.
Facilitate health promotion education/training for health service staff.
Provide expert knowledge in health promotion acting as a consultant to health providers,
making recommendations for future health promotion programs that are consistent with
strategic direction.
Conducts literature reviews, needs assessments and undertakes research in health promotion
related topics to identify gaps and needs in service provision.
Local contact details:
Avon and Central Wheatbelt Primary Health - Based in Northam and covering York, Beverley,
Quairading, Cunderdin, Tammin, Meckering, Dowerin, Goomalling, Toodyay, Wundowie and Northam.
Postal Address: PO Box 312, Northam WA 6401
Phone: 9690 1320
Fax: 9690 1694
Eastern Wheatbelt Primary Health - Based in Merredin and covering, Bruce Rock, Kellerberrin,
Narembeen, Southern Cross, Westonia, Nungarin, Trayning, Kununoppin, Wyalkatchem, Koorda, Beacon,
Bencubbin, Mukinbudin, Moorine Rock, Muntadgin, Doodlakine and Merredin.
Postal Address: PO Box 327, Merredin WA 6415
Phone: 9041 0444
Fax: 9041 0424
Southern Wheatbelt Primary Health - Based in Narrogin and covering West Arthur, Williams,
Cuballing, Lake Grace, Wickepin, Kondinin, Corrigin, Wagin, Kulin, Dumbleyung, Pingelly and Narrogin.
Postal Address: PO Box 477, Narrogin WA 6312
Phone: 9881 0385
Fax: 9881 0457
Western Wheatbelt Primary Health - Based in Moora and covering Moora, Miling, Watheroo,
Dandaragan, Jurien Bay, Cervantes, Badgingarra, Dalwallinu, Kalannie, Pithara, Wubin, Buntine, Gingin,
Lancelin, Guilderton, Seabird, Ledge Point, Wongan Ballidu, Wongan Hills, Ballidu, Cadoux, Victoria
Plains, Calingiri, Yerecoin, Bolgart, Mogumber, Gillingarra, Chittering, Bindoon, Muchea, Wannamal,
Dowerin and Goomalling.
Postal Address: PO Box 154, Moora WA 6510
Phone: 9651 0270
Fax: 9651 0284
Wheatbelt Aboriginal Health Service - Based in Northam and covering the whole Wheatbelt.
Postal Address: PO Box 407, Northam WA 6401
Phone: 9690 2888
Fax: 9690 2850
Wheatbelt Public Health Unit - Based in Northam and covering the whole Wheatbelt.
Postal Address: PO Box 337, Northam WA 6401
Phone: 9622 4320
Fax: 9622 4342
Page 2
Population Health - Wheatbelt
Primary Health Services in the Avon and Central, Eastern, Southern and Western Wheatbelt
Wheatbelt Public Health Unit and Wheatbelt Aboriginal Health Service