CPP Initiation Fund Application – Public Health Institute of Oklahoma

Name of Coalition, Collaborative, Partnership working to host your community-based testing event? *

Point of Contact Name *

First

Last

Email *

Phone Number *

Preferred Method of Contact *

Secondary Contact Name

First

Last

Would you like to apply for Community Partnership Program Developmental Start-Up Funds? *

Yes, I will be able to provide a W9
Yes, but I need a nonprofit partner
No and/or Not sure

Please upload current year (2021) W9 here. If unavailable at this time, W9 can be emailed to info@publichealthok.org however please note that this may slow down the fund distribution.

Click or drag a file to this area to upload.

Would you like for this event to be a recurring? *

Yes
No
Not sure yet

County your event will be held in? *

Please select any additional counties you anticipate being served by your event: *

Proposed Event location (Please provide full address if known): *

Do you need support publicizing the event? *

If you chose "Other" above, please list language:

Tell us about the type of Coalition/Partnership volunteer base you will activate to staff your testing event? *

Do you have a target population for your event? (choose all that apply) *

If you chose "Other" above, please briefly describe your target population:

What are your primary and secondary goals for the testing event? *

Community-based testing events present an opportunity to include social determinant of health interventions, how might your testing event meet current community needs: (For example, food, clothing, resources, flu shots) *

Please descibe existing partnerships you will utilize in organizing, publicizing and staffing your event? *

If you are located within a tribal jurisdiction, do you have tribal support/involvement? *

Yes
No
Not applicable

If you chose "Yes" above, please describe:

If you plan to pair this testing event with a previously scheduled community health improvement or promotion activity, please list it below: (i.e., backpack or free/reduce lunch event)

Does the Coaliition/Partnership requesting the testing event have a relationship with any of the following at the local level?

Department of Emergency Management
City Manager
Health Department

Does your Coalition/Partnership plan on organizing a Task Force/Sub-Committee etc., to assist in local testing event efforts? *

If you answered "Yes" above, please let us know know when and how you plan on meeting.

If you answered "No" above, please let us know where event planning activities will occur.

To assist in our program evaluation efforts, we encourage you to complete the following section. Please note, however, that it is not required and this section will have no impact on your ability to receive start-up funds. We value and appreciate your time!

Name three individuals within your coalition whom you go to for advice? (In no particular order) *

First

Last

2. *

First

Last

3. *

First

Last

Please rate your perception of the following: Within our coalition, there is strong leader-member communication:

The well-being of individuals in our community has changed over the past year due to our coalition activities:

Has your coalition explored potential funding sources similar to project CATCH-UP?

Please provide a general estimate of the number of members within your coalition:

Please provide a best guess of when your coalition was first established: