OU Rural Health Smartphone Study – Public Health Institute of Oklahoma

Apply below to be a partner to this project.

Organization/Coalition Name: *

Mission Statement of the organization: *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Counties served: *

What quadrant(s) of the state do you serve? *

Name *

First

Last

Contact Person Name

Email *

Phone *

Are you a coalition that is a certified County Health Improvement Organization?

Are you a CATCH-UP Partner? *

Can your organization provide a W9? (if PHIO does not have it already) *

Please share outreach and recruitment activities and/or partners you will use to recruit up to 4 Substance Use study participants: (Flyer, Ad, FAQ is provided to support your efforts) *

How many participants are you planning to recruit and from what counties? *