UCCC Focus Group Proposal Form

Topic of proposed group:

Type of group (select one):

Description of proposed group:

Number of group members: Minimum:     Maximum:

Frequency of meetings you envision for this group (ie. Weekly, monthly):

If this is a Peer type group, are you willing to be the facilitator? Yes     No     Maybe

If this is a Mentored group, are you volunteering to be the facilitator/mentor? Yes     No

Your name:

Your email address: