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.

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

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* 2. What is your regional affiliation based on the OCPIM map?

Northwest

Northeast

Central

Southwest

Southeast

Statewide

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* 3. Are there efforts in your community/county specifically focused on infant mortality?

Yes

Don't know

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* 4. Please list the efforts in your community/county that are specifically focused on infant mortality.

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* 5. Are you currently involved in local efforts related to infant mortality/birth outcomes/maternal and child health?

Yes

Not sure

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* 6. Which format would you prefer for regional meetings?

Conference call

Video conference

In person

Combination of the above

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* 7. Please rank the 4 OCPIM priority areas based on your community's needs.

Community Engagement and Participation

Exchange of Novel Intervention and Practices

Advocacy

Data

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* 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-

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* 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

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* 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

OCPIM Regional Membership Application

What is your region?

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

Question Title

* 2. What is your regional affiliation based on the OCPIM map?

Question Title

* 3. Are there efforts in your community/county specifically focused on infant mortality?

Question Title

* 4. Please list the efforts in your community/county that are specifically focused on infant mortality.

Question Title

* 5. Are you currently involved in local efforts related to infant mortality/birth outcomes/maternal and child health?

Question Title

* 6. Which format would you prefer for regional meetings?

Question Title

* 7. Please rank the 4 OCPIM priority areas based on your community's needs.

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.

Question Title

* 9. By completing the following, you agree to be an active and contributing member of the Ohio Collaborative to Prevent Infant Mortality.

Question Title

* 10. Complete the following in association with your OCPIM participation:

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* 11. Are you interested in committee role?

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* 12. We welcome further comments or questions here.