CHIO Readiness

Certification Readiness Assessment Tool

Completion of this form helps us to determine your readiness for CHIO Certification which connects communities to health improvement opportunities.

*Please note: Applying organizations are not required to meet all CHIO Readiness elements. The CHIO Readiness Form and Application will serve as a Quality Improvement tool to assist your entity in achieving its health and wellness related goals.

Entity Name *

Community/County(ies) served: *

Primary Contact Name and Phone Number *

Primary Contact Email *

Were you referred by someone for the CHIO network? If so, by whom

Social Media Outlets (Facebook, Instagram, TikTok, others *

Website / URL

Please provide your mission/vision or purpose statement. *

Describe the programs and services your organization offers. *

What type of CHIO Certification are you applying for? *

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 + (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

Why is your organization interested in applying to become a CHIO? *

Does your organization collaborate around health improvement priorities and/or wellness goals to support your community and your community members? *

Yes
No

Are you a 501(c)3 or does an external organization support your efforts? *

Yes
No

If no, please name the organization supporting you.

What population does your organization serve? *

Urban
Rural
Both

Share with us who is involved in your local health improvement activities. Check all that apply. *

Primary Care
Social Services
Health Department
Mental Health
Faith Community
Philanthropic Groups
Hospital
Businesses
Extension System
Financial Institutions
Long Term Care
Civic Groups
Elected Officials
Media
Law Enforcement/First Responder/Public Safety
Higher Education
FQHC/Community Health Centers
Youth Development
Child Development
Dept. Health & Human Services
Public Schools
Other

Do you have health care providers participating in your health related activities? *

Yes
No

Are you engaged or did you help with your Community Health Needs Assessment or County Health Improvement Plan activities as an entity? *

Yes
No

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

Yes
No

Do you have a Board of Directors or a leadership structure supporting your organization? *

Yes
No

Does your organization meet regularly (monthly, quarterly, etc)? *

Yes
No

Does your organization include community members in planning and implementing health improvement activities locally? *

Yes
No

Thank you for completing your CHIO Readiness Assessment. A team member with the Public Health Institute of Oklahoma will be in touch to discuss next steps.

*Please note: Applying organizations 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.

Questions? Need more information? Email kayla@publichealthok.org or info@publichealthok.org.

Mailing Address- P.O. Box 60926, Oklahoma City, OK 73146-0926 Physical Address- 1141 W Sheridan Oklahoma City, OK 73106 Phone: (405) 259-6851 Email: info@publichealthok.org