Ohio Collaborative to Prevent Infant Mortality (OCPIM) - Community Change Agent Interest Questionnaire

Please submit by April 11, 2022

Question Title

1. Personal Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

County

Email Address

Phone Number

Question Title

2. To what degree do you feel your lived experience has prepared you to become a community change agent?

A great deal

A lot

A moderate amount

A little

None at all

Question Title

3. Please, rank the following traits you feel are the most important to have working as a change agent.

Question Title

4. What is the infant mortality rate in the county you live in?

Question Title

5. How familiar are you with the term birth equity?

Extremely familiar

Very familiar

Somewhat familiar

Not so familiar

Not at all familiar

Question Title

6. How familiar are you with the term reproductive justice?

Extremely familiar

Very familiar

Somewhat familiar

Not so familiar

Not at all familiar

Question Title

7. To what degree does racism contribute to Black babies dying?

A great deal

A lot

A moderate amount

A little

None at all

Question Title

8. Have you advocated for others as a result of unfair treatment?

Yes

Question Title

9. Would you be willing to work six hours per month for five months, as a community change agent, to build awareness and engage communities to improve pregnancy and infant health?

Yes

Question Title

10. Please, describe your experience and interest in working with people from diverse backgrounds (including race, culture, gender, sexual orientation, religion, socioeconomics, age, etc.).

Ohio Collaborative to Prevent Infant Mortality (OCPIM) - Community Change Agent Interest Questionnaire

Please submit by April 11, 2022

Question Title

* 1. Personal Information

Question Title

* 2. To what degree do you feel your lived experience has prepared you to become a community change agent?

Question Title

* 3. Please, rank the following traits you feel are the most important to have working as a change agent.

Question Title

* 4. What is the infant mortality rate in the county you live in?

Question Title

* 5. How familiar are you with the term birth equity?

Question Title

* 6. How familiar are you with the term reproductive justice?

Question Title

* 7. To what degree does racism contribute to Black babies dying?

Question Title

* 8. Have you advocated for others as a result of unfair treatment?

Question Title

* 9. Would you be willing to work six hours per month for five months, as a community change agent, to build awareness and engage communities to improve pregnancy and infant health?

Question Title

* 10. Please, describe your experience and interest in working with people from diverse backgrounds (including race, culture, gender, sexual orientation, religion, socioeconomics, age, etc.).

1. Personal Information

2. To what degree do you feel your lived experience has prepared you to become a community change agent?

3. Please, rank the following traits you feel are the most important to have working as a change agent.

4. What is the infant mortality rate in the county you live in?

5. How familiar are you with the term birth equity?

6. How familiar are you with the term reproductive justice?

7. To what degree does racism contribute to Black babies dying?

8. Have you advocated for others as a result of unfair treatment?

9. Would you be willing to work six hours per month for five months, as a community change agent, to build awareness and engage communities to improve pregnancy and infant health?

10. Please, describe your experience and interest in working with people from diverse backgrounds (including race, culture, gender, sexual orientation, religion, socioeconomics, age, etc.).