CHIO Application – Public Health Institute of Oklahoma

– Step 1 of 3

What you’ll need before you begin:

What you’ll need before you begin: • Organizational bylaws or governance documents to upload • List of Board members, governing board, or executive committee to upload • Letters of support (minimum 2) from collaborating organizations to upload • 1 Cover letter to upload Templates of all of the above are found on the PHIO website under Community Health Improvement Programs.

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. Application will be reviewed by the CHIO Certification Review Committee (30-60 days).

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.

Entity Name *

Community/County(ies) served: *

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

What type of CHIO Certification are you applying for? Select Your Certification Level: Definition: Certification levels are based on geographic service area. *

Community Health Improvement Organization (cHIO): Serves individuals within one specified geography (census tract, zip code, town, city, or municipality). Examples: local civic groups, faith-based organizations, small non-profits, local Chambers of Commerce, local governments, local primary and secondary institutions.
County Health Improvement Organization (CHIO): Serves individuals across multiple geographies with no more than 2 entire counties. Examples: 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 (CHIO+): Serves individuals across 3 or more counties or statewide. Examples: large multi-county coalitions and task forces, hospitals and clinic systems, State Agencies, Tribes, Professional Associations, 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) *

Quarterly Learning Exchanges
Rural Health Listening Sessions (Prime-OK)
Rural Health Innovation Challenge
Handle With Care Oklahoma
CATCH-UP Testing or Vaccine
None of the above

Section 1: Organizational Profile

This section helps us understand your organization structure and capacity.

1. What type of organization are you? *

nonprofit 501(c)3
for profit
coalition
governmental
Community group or grassroots organization
Task Force
describe my organization (if chosen, please describe in the space provided)

Describe the organization if needed.

2. What population do you serve? *

Urban
Rural
Both

3. Do you utilize another organization as a fiscal agent? (If NO, skip next question) *

4. Please name the fiscal agent supporting your organization.

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

6. If applicable, please provide us your organizational website, dashboard and/or Facebook.

7. Please list meeting date/time, location and frequency. *

Virtual Link

8. Do you have a Governing Board/Board of Directors/Executive Committee? *

If yes, please upload a list of board members with the application. Template is found on the CHIO webpage.

Drag & Drop Files, Choose Files to Upload

9. Do you have established policies and procedures or by-laws as an organization? *

If yes, please upload your established policies and procedures or by-laws with the application.

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Community Engagement

10. Do you have volunteers supporting your entity? (If NO, skip next question) *

11. Please detail how volunteers are recruited, supervised, and utilized.

12. Do you have community members participating in your activities? (If NO, skip next question) *

13. Please describe how community members participate.

14. Do you remove barriers for underserved community members (e.g., providing childcare, food, transportation assistance, stipends, or other supports to enable participation in planning and implementing health improvement activities)? (If NO, skip next question) *

15. Please detail the barriers you address and how.

Communication and Outreach

16. Do you use social media to support your efforts? *

17. Please indicate platforms utilized:

Facebook
Instagram
LinkedIn
TikTok
YouTube
Twitter/X
Other

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Section 2: Entity Focus & Activities

This section examines your health improvement priorities and current work.

18. Does your organization have a specific topical focus? (e.g., substance abuse prevention, maternal health, mental health, etc.) (If NO, skip next question) *

19. If yes, please describe.

20. Are there any areas you hope to address in the future but don’t currently? (If NO, skip next question) *

21. If yes, please describe.

22. Briefly describe the types of health improvement activities your organization is involved in or conducts. *

23. Does your organization participate in the development of your local Community Health Needs Assessment (CHNA)? (If NO, skip next question) *

24. If yes, please describe your participation.

25. Does your entity participate in the development of your local County Health Improvement Plan (CHIP)? (If NO, skip next question) *

26. If yes, please describe your participation.

27. Has your entity adopted the locally developed CHNA/CHIP as a guiding document to drive health care improvements locally? (If NO, skip next question) *

28. If yes, please upload document.

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

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Section 3: Stakeholders and Partnerships

This section identifies your collaborative partnerships.

30. Please indicate which sectors are currently involved in your health improvement activities: (Check all that apply)

Healthcare Providers

Primary Care
Hospital
Rural Clinic
FQHC/Community Health Center
Mental Health
Long-term care
Tribal health facility

Government/Public Services

County Health Department
Social services
Elected Officials
Law enforcement/first responders/public safety
Court systems

Education

Public Schools
Private Schools
Higher Education
Vocational Education

Community Organizations

Faith Community
Philanthropic Groups
Civic Groups
Non-profit Organizations
Youth Development
Child Development

Business/Economic

Businesses
Financial Instiutions
Accounting/CPA

Support Services

Legal Supports
Housing Supports
Food Bank
Extension system
Media

Civic/Fraternal Groups

Rotary Club
Lions Club
Masons
Shriners
Kiwanis
Sertomas
Oddfellows
College Fraternities/Sororities
Ministerial Alliance
Other civic or fraternal groups

Community Organizations

Local Untied Way
Chamber of Commerce
Main Street or Downtown Association
4H Clubs, Ag Clubs

State Agencies

Deptartment 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)
TSET (Tobacco Settlement Endowment Trust) Oklahoma Health Care Authority
Oklahoma Department of Rehabilitation Services Oklahoma Bureau of Narcotics
Office of Juvenile Affairs
Oklahoma Department of Veterans Affairs Oklahoma institute for Child Advocacy
Department of Corrections

Legal Services

Legal Aid Services of Oklahoma
Sooner Success

Public Safety

Fire
Ambulance/EMSA
Policy
Other

31. Which types of healthcare providers are involved in your health improvement efforts? (Check all that apply) *

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

32. If applicable, what are your community’s most challenging provider shortage gaps?

33. Are any of the following services available within your service area? (Check all that apply)

Trauma-Informed/Resilience Services

Trauma/NEAR Science/Hope Trainings
Handle With Care OK
Multi-Tiered Systems of Support/Multi-Disciplinary Teams
Self-Healing Community

Substance Use Services

MAT services (medication assisted therapy)
Rehabilitation/Detoxification Services
Inpatient treatment services
Peer Support Groups

Family Support Services:

Parent Partnership Advisory Committees
Fatherhood initiatives
Maternal Child Health initiatives (Children First, Healthy Start, etc.)
Domestic violence services

Youth Services

Youth Advisory Councils
Project Aware Site

Community Resources

HOPE Center/Family Resource Center
Systems of Care Coalition

34. Are you a member of the following Professional Organizations or Networks. (Check all that apply)

Rural Health Association of Oklahoma
National Rural Health Association
Oklahoma Turning Point Council
Oklahoma Public Health Association
Oklahoma Center for Non-Profits the Standards of Excellence Training
Oklahoma Primary Care Association
Other

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 acknowledge PHIO may utilize Facebook, Twitter, Instagram, other social media platforms, newsletter 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 a Cover letter from applying entity confirming intent to apply for CHIO Certification. Cover letters must be signed by submitting individual and appropriate leadership. Template is available on the PHIO website. *

Drag & Drop Files, Choose Files to Upload

Please upload a Minimum of 2 Letters of Support from collaborating stakeholders indicating your entity’s ability to support health improvement activities within the communities/counties you are seeking to Certify. Template is available on the PHIO website. *

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

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