OCPIM Regional Membership Application What is your region? The information that you provide will be used by your regional co-leads to contact you regarding future meetings and to provide you with additional information. OK Question Title * 1. Please review the OCPIM regional map to determine your region.https://www.baby1stnetwork.org/sites/default/files/editor/OCPIM%20Map%2020190105%20%281%29_0.pdf PDF file types only. Choose File Choose File No file chosen Remove File Please review the OCPIM regional map to determine your region.https://www.baby1stnetwork.org/sites/default/files/editor/OCPIM%20Map%2020190105%20%281%29_0.pdf OK Question Title * 2. What is your regional affiliation based on the OCPIM map? Northwest Northeast Central Southwest Southeast Statewide OK Question Title * 3. Are there efforts in your community/county specifically focused on infant mortality? Yes No Don't know OK Question Title * 4. Please list the efforts in your community/county that are specifically focused on infant mortality. OK Question Title * 5. Are you currently involved in local efforts related to infant mortality/birth outcomes/maternal and child health? Yes No Not sure OK Question Title * 6. Which format would you prefer for regional meetings? Conference call Video conference In person Combination of the above OK Question Title * 7. Please rank the 4 OCPIM priority areas based on your community's needs. 1 2 3 4 Community Engagement and Participation 1 2 3 4 Exchange of Novel Intervention and Practices 1 2 3 4 Advocacy 1 2 3 4 Data OK Question Title * 8. List up to 3 key themes that should underscore your region's efforts to eliminate disparities in infant mortality. For example, structural racism. Key Theme- Key Theme- Key Theme- OK Question Title * 9. By completing the following, you agree to be an active and contributing member of the Ohio Collaborative to Prevent Infant Mortality. Name Title Organization OK Question Title * 10. Complete the following in association with your OCPIM participation: Address Address 2 City/Town State/Province ZIP/Postal Code County Email Address Phone Number OK Question Title * 11. Are you interested in committee role? Yes No Not Sure OK Question Title * 12. We welcome further comments or questions here. OK DONE
