CHIO Application – Public Health Institute of Oklahoma

– Step 1 of 3

Completion of this application helps us to determine your fit for CHIO Certification, which connects communities to health improvement opportunities and resources..

If you need to save your application and return to it, please make sure to copy the link on the second window. Your work will not save by hitting save at the end of the page. You need to copy the link in order to return to your application.

Please complete the following application to be considered for your CHIO Certification. Application template is consistent across all levels of Certification. *Completed applications will be reviewed in January, April, July, and October annually.

*Staff members from the Public Health Institute of Oklahoma are available to help in the completion and submission of your application. If you need to save your application and resume later, please click the save and resume later button below. You will need to copy the link provided.

*Please note: Applying entities are not required to meet all CHIO Certification elements. The CHIO Certification Application will serve as a Quality Improvement tool to assist your entity in achieving its health and wellness related goals. Recommendations will be provided by the CHIO Certification Review Committee upon review of your application.

Entity Name *

Community/County(ies) served: *

Primary Contact Name and Info (name, email, phone number): *

Preferred method of communication *

Text
Call

What type of CHIO Certification are you applying for? *

community Health Improvement Organization Your entity (or collective) serves individuals within one specified geography. This could be at the census tract, zip code, town, city, or municipality level. Examples include: local civic groups, faith-based organizations, small non-profits, local Chambers of Commerce, Local Governments, local primary and secondary educational institutions
County Health Improvement Organization Your entity (or collective) serves individuals within multiple geographies but constitutes no more than 2 entire counties. This could include multiple census tracts, zip codes, towns, cities, or municipalities. Examples include: large non-profits, local coalitions and task forces, special interest groups, local clinics and FQHCs, large faith-based organizations, philanthropic organizations, large civic organizations, financial institutions, vocational education institutions, law enforcement agencies
County Health Improvement Organization Plus+ Your entity (or collective) serves individuals within multiple geographies of a minimum of 3 or more counties. This could include multiple census tracts, zip codes, towns, cities, or municipalities. Examples include: large multi-county coalitions and task forces (3 or more counties served), hospitals and clinic systems, State Agencies, Tribes, Professional Associations, Special Interest Groups, financial institutions, vocational education institutions, law enforcement agencies, philanthropic organizations

Was your organization certified as a CHIO in the past? *

Yes
No
Not sure

Has your organization worked with PHIO on another project? (Check all that apply) *

CATCH-UP Testing or Vaccine
Rural Health Innovation Challenge
Handle With Care Oklahoma
Parent Partnership Learning Communities
Oklahoma Turning Point Council
Quarterly Learning Exchanges
Peer Support Groups
Other

Section 1: Entity Information

1. Please tell us a bit about your entity type. *

nonprofit 501(c)3
for profit
governmental
at-large community group
describe my entity (if chosen, please describe in the space provided)

Describe the entity if needed.

2. Does your entity serve a rural or urban population? *

Rural
Urban
Both

3. Does your entity utilize another organization as a fiscal agent? *

If yes, please name the fiscal agent supporting your entity.

4. Please share your organizational mission, vision, and purpose with us: *

5. Please provide us your organizational website: *

6. Please tell us a bit more about your organizing style. Are you a Coalition, Task Force, or like entity? *

If yes, please share when you host your regularly scheduled meetings, including any workgroups, committees, etc. associated with your work.

7. Do you have a Governing Board? *

If yes, please describe their function.

When does your Governing Board meet?

If you do not have a Governing Board, how does your entity make decisions?

8. Do you have a Parent Partnership Advisory Committee? *

If yes, please describe their function.

9. Do you have a Youth Advisory Committee? *

If yes, please describe their function.

10. Do you have volunteers supporting your entity? *

If yes, please detail how volunteers are recruited, supervised, and utilized.

11. Do you have community members participating in your activities? *

If yes, please describe how community members participate.

12. Does your entity remove barriers for underserved community members to participate in planning and implementing health improvement activities locally (such as childcare, food, transportation assistance, stipend, etc)? *

If yes, please detail.

13. Please be prepared to share with PHIO and the CHIO Certification Review Committee a copy of your by-laws or guiding governance documents.

14. Does your entity utilize social media outlets in support of your efforts? Please select platforms utilized and note usernames and hashtags utilized in promoting your efforts. *

Facebook
Twitter
Instagram
YouTube
LinkedIn
TikTok

Please share your usernames below. *

Please share with us any hashtags or promotional language you would like us to use in promoting your efforts.

Section 2: Entity Focus & Activities

15. Does your entity have a topical focus? *

If yes, please describe.

16. Please describe the areas of practice/service delivery your entity addresses. *

17. Are there any areas of practice/service delivery your entity does not currently address yet hopes to address in the future? *

If yes, please describe.

18. Briefly describe the types of health improvement related activities your entity is involved in. *

19. Does your entity participate in the development of your local Community Health Needs Assessment? *

If yes, please describe your participation.

20. Does your entity participate in the development of your local County Health Improvement Plan? *

If yes, please describe your participation.

21. Has your entity adopted the locally developed CHNA/CHIP as a guiding document to drive health care improvements locally? *

If not, please detail your limitations related to adopting the CHNA or CHIP.

22. Please share the Top 3 goals your entity hopes to accomplish in the next 5 years. *

Section 3: Education & Communications

23. Does your entity have the ability to host educational events? *

24. What types of educational events do you offer? Please choose all that apply. *

Web-based
In-person
Free educational events
Paid educational events
Open to the public events
Other

If not, please detail your limitations related to offering web-based education.

25. Does your entity offer CEUs/CMEs for your educational events? *

If yes, please note types offered.

26. Does your entity remove barriers for underserved community members to participate in educational opportunities (such as childcare, food, transportation assistance, stipend, etc)? *

If yes, please share how barriers are removed.

27. If you currently offer educational events, please list your top 5 educational events annually.

28. Does your entity desire to offer educational events to support your operations, growth, and community need? *

If yes, please share the topics you require assistance to host an educational event.

29. Does your entity have the ability to host virtual, web-based meetings? *

If no, please share the your limitations.

30. Please detail the typical way your entity shares information with your stakeholders? *

31. Please share your top challenges in communicating with you stakeholders and community members. *

Section 4: Stakeholder and Membership Profile

32. Please indicate the current collaboration of sectors involved in your health improvement activities. Please note not all are required to achieve CHIO Certification.

primary care
county health department
behavorial health
social services
faith community
philanthropic groups
hospital
rural clinic
businesses
extension system
legal supports
financial institutions
long term care
civic groups
elected officials
media
law enforcement/first responders/public safety
higher education
vocational education
accounting/CPA
FQHC/Community Health Center
youth development
tribal health facility
child development
public schools
private schools
housing supports
court systems
non-profit
food bank

33. We would like to learn more about with what specific groups you work. Please indicate if any of the following groups/agencies/or organizations are active participants in your health improvement activities. *

Rotary Club
Lions Club
Masons
Shriners
Kiwanis
Sertomas
Oddfellows
College Fraternities and Sororities
other civic or fraternal groups
Dept. of Human Services
Oklahoma Dept. of Mental Health & Substance Abuse Services
Oklahoma State Department of Health
Oklahoma Turning Point Council
Oklahoma Commission on Children & Youth
WIC-Women, Infant, and Children (Nutrition program)
TSET (Tobacco Settlement Endowment Trust)
Oklahoma Health Care Authority
Oklahoma State Department of Health
Oklahoma Department of Rehabilitation Services
Oklahoma Bureau of Narcotics
Office of Juvenile Affairs
Oklahoma Department of Veteran Affairs
Oklahoma Institute for Child Advocacy
Department of Corrections
Legal Aid Services of Oklahoma
Sooner SUCCESS
Ministerial Alliance
local United Way
Chamber of Commerce
Main Street or Downtown Association
4H Clubs, Ag Clubs
Tribal
Public Safety Entities
Fire
Ambulance/EMSA
Police
Other Public Safety Entity

34. Do you have the following health care providers involved in your health improvement efforts? *

primary care provider
pediatrician
nutritionist
behavioral health provider
occupational therapist, physical therapist, etc.
dentistry
ophthalmologic (eye care)
other provider types involved
none of the above

Please share your community’s most challenging provider shortage gaps. *

35. Do you have the following services available within the geography/community you are seeking to certify? *

Trauma/NEAR Science/Hope Trainings
Handle With Care OK
Multi-Tiered Systems of Support/Multi-Discplinary Teams
MAT services (medication assisted therapy)
Detox Services
inpatient treatment services
Peer Support Groups
Parent Partnership Advisory Committees
domestic violence services
Youth Advisory Councils
Fatherhood initiatives
Maternal Child Health initiatives (Children First, Healthy Start, etc.)
Systems of Care Coalition
Project Aware Site
HOPE Center/Family Resource Center
Self-Healing Community

Please provide listing of group types:

36. Are you a member of the following Professional Organizations or Networks: *

Oklahoma Primary Health Care Extension System
Rural Health Association of Oklahoma
National Rural Health Association
Rural Health Network of Oklahoma
Oklahoma Turning Point Council
Oklahoma Public Health Association
Oklahoma Center for Non-Profits the Standards of Excellence Training
Oklahoma Primary Care Association
None of the Above

37. Has your entity participated in any of the following? *

HOPE training
Resiliency Film screening
N.E.A.R. Science Training
None of the Above

38. Please provide the following attestations: *

Please select to acknowledge Partnership Agreements, Memorandums of Understanding, Business Associate Agreements, Data Sharing Agreements may be required based upon available collaborative opportunities.
Please select to acknowledge CHIO Certification application was completed by a member of the entity, not a member of the PHIO or OPHES team.
Please select acknowledge PHIO will utilize Facebook, Twitter, Instagram, other social media platforms and electronic mailings to communicate and promote information related to individual and shared activities of all CHIOs and OPHES members.
All CHIO Certification applications will also include no-cost membership application to the Oklahoma Primary Health Care Extension System.

NOTE: the final sections require file uploads. Uploads WILL NOT be saved using the "Save and Resume Later" function. Uploads will only be saved if the form is submitted.

Please upload bylaws or guiding governance documents. *

Click or drag files to this area to upload. You can upload up to 3 files.

Please upload a listing of entity stakeholders/coalition members/governing body to include name, email, and organization, and communities or counties served. Please note all provided names will be incorporated into the PHIO/CHIO electronic newsletter mailing list to ensure your stakeholders are up-to-date on all current health improvement *

Click or drag files to this area to upload. You can upload up to 3 files.

Please upload a Cover letter from applying entity confirming intent to apply for CHIO Certification. Cover letters must be signed by submitting individual and appropriate leadership. *

Click or drag a file to this area to upload.

Please upload a Minimum of 1 Letter of Support from collaborating stakeholders indicating your entity’s ability to support health improvement activities within the communities/counties you are seeking to Certify. *

Click or drag files to this area to upload. You can upload up to 5 files.

County Health Improvement Plan or Assessment

Click or drag a file to this area to upload.

If you have your latest county health improvement plan or assessment, please upload it. It is not required.

Important Information

If you choose to save this application and resume later, please copy the link you are given. There is not another way to receive that link again.

Single Line Text

File Upload

Click or drag a file to this area to upload.