CATCH-UP Vaccine Hesitancy Cohort Application Please enable JavaScript in your browser to complete this form.Organization Details - Step 1 of 5Name of Organization *Please identify your organization type: *For profitNon-profitFaith-basedCivic organizationOtherOther, please identify:Do you currently provide direct services to your community? *YesNoIf yes, please identify provided services:Physical Address: *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIs this different than mailing address? *YesNoMailing Address:Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCommunity Classification: *UrbanRuralOtherIf other, please specify:Does the organization have a website? *YesNoOrganization Website / URLDoes the organization have social media accounts? *YesNoPlease provide links to social media platforms: Primary Contact Name: *FirstLastPhone Number of Primary Contact: *Email of Primary Contact: *Please share the mission of your organization and describe what makes your organization a good match for the project.:Were you a previous CATCH-UP Oklahoma Testing Site Partner? *YesNoDo you have an account in IMMY the COVID-19 testing scheduling platform with the Oklahoma State Department of Health? *YesNoAre you willing to have the CATCH-UP Vaccine Hesitancy Team as a component of your event? *YesNoNeed more detailsAre you willing to participate in a compensated National Institute of Health media photo shoot showcasing your event? *YesNoNeed more detailsNextPlease list your top 5 community social and health needs: *Please provide data to support your identified need.Please list the top 5 anecdotal needs of your community: *We support the engagement of individuals distinctively equipped to understand the unique challenges of their communities.Please provide details on your community’s COVID-19 vaccine environment: *PreviousNextWhen are you available to host your event? Please rate your choice of dates by using the smiley faces. 1st choice: 3 smiles, 2nd choice: 2 smiles, 3rd choice: 1 smile *Rate 1 out of 3Rate 2 out of 3Rate 3 out of 3May 2022When are you available to host your event? Please rate your choice of dates by using the smiley faces. 1st choice: 3 smiles, 2nd choice: 2 smiles, 3rd choice: 1 smile *Rate 1 out of 3Rate 2 out of 3Rate 3 out of 3June 2022When are you available to host your event? Please rate your choice of dates by using the smiley faces. 1st choice: 3 smiles, 2nd choice: 2 smiles, 3rd choice: 1 smile *Rate 1 out of 3Rate 2 out of 3Rate 3 out of 3July 2022Describe community event to be held: *County of community: *Event is planned to be: *IndoorOutdoorIf outdoor, please detail your inclement weather plan.:Do you have an event venue in mind? *YesNoIf yes, please list:Does the venue have electricity hookups?YesNoDoes the venue have the ability to park a semi-truck on-site?YesNoAnticipated number of event attendees: *Please describe the anticipated demographics of event attendees: *Do you plan on offering COVID-19 Rapid and PCR testing at your event? *YesNoDo you have nursing staff available to administer testing?YesNoNursing staff is:PaidVolunteerWhat types of services would you like to offer at your event? *Do you have the ability to provide opioid supports or harm reduction services at your event? *YesNoPlanning DetailsPlease share who will be involved in planning for your event? *Please share how you will organize your event. For example, will you use a committee(s) or working group(s) to organize the event? *Do you have a volunteer base to support your event? Please provide an estimate of the number of volunteers you will have available for the day of the event? *PreviousNextDo you have an established relationship with your local county health department? *YesNoIf yes, please provide the name and title of your contact:Please detail your proposed engagement with the primary care community: *Please detail your plan for community engagement: *Do you currently have a connection to the faith-based community? If yes, please provide details: *How do you plan to engage the media in support of your event? *PreviousNextPlease upload your 2022 W9: * Click or drag a file to this area to upload. Submit