Shortened Quality Form Please enable JavaScript in your browser to complete this form.Local Community Advisor Feedback Form: Quality Improvement & Community VoiceYour voice is very important to improve systems throughout Oklahoma. To increase equity and address Covid-19 health disparities, the Public Health Institute of Oklahoma and the CATCH-UP 2.0 Project advances family voice to increase quality AND removes barriers for participation, as funding is available. This agreement is entered into between Public Health Institute of Oklahoma and the community advisor listed below for the purposes of collecting quality feedback and providing compensation and/or reimbursements for community advisor/family leadership activities, as funding is available.Section 1: Contact InformationJoin our team of family leaders/community champions!County *Panhandle Region: Texas County, Beaver, CimarronNorthwest Region: Alfalfa, Grant, GarfieldSouthwest Region: Stephens, JeffersonCentral Region: Oklahoma CountyNortheast Region: Rogers, Wagoner, Delaware, CherokeeSoutheast Region: Latimer, Le FloreWhat county or counties do you live in or work in currently?Name *FirstLastAddress *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Phone *Name of Regional Coordinator who provided you this form: *Date of meeting/activity that you attended (month, day and year): *Name of activity (meeting, conference, training, etc.): *Length of activity/meeting (including prep time, debriefing after meeting, and this feedback form): *30 min1 hour2 hours3 hours4 hours6+ hoursDid you participate "on the clock" or "off the clock"? *“on the clock” – State employees do not qualify for stipend or reimbursement“on the clock” – Paid private employee; Part of job description/contract pays for time“off the clock” – Paid private employee; duties outside any current contract hours“off the clock” – Unemployed/volunteer family leader/youth leaderKey take-aways from event/meeting: *What went well? *What needs improvement? Any barriers or solutions identified? *Thank you for your time and valuable feedback. Do you have other comments/ideas/suggestions?Internal Use Only* – Was payment provided by Regional Coordinator?YesNot yetPayment is not neededInternal Use Only* – What type of payment was given by Regional Coordinators?Gift CardVoucherCashInternal Use Only*-What are the last four of the gift card?Submit
