CATCH-UP Vaccine Hesitancy Cohort Application – Public Health Institute of Oklahoma

Name of Organization *

Please identify your organization type: *

For profit
Non-profit
Faith-based
Civic organization
Other

Other, please identify:

Do you currently provide direct services to your community? *

If yes, please identify provided services:

Physical Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Is this different than mailing address? *

Mailing Address:

Address Line 1

Address Line 2

City

State

Zip Code

Community Classification: *

Urban
Rural
Other

If other, please specify:

Does the organization have a website? *

Organization Website / URL

Does the organization have social media accounts? *

Please provide links to social media platforms:

Primary Contact Name: *

First

Last

Phone 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? *

Do you have an account in IMMY the COVID-19 testing scheduling platform with the Oklahoma State Department of Health? *

Are you willing to have the CATCH-UP Vaccine Hesitancy Team as a component of your event? *

Yes
No
Need more details

Are you willing to participate in a compensated National Institute of Health media photo shoot showcasing your event? *

Yes
No
Need more details

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Please 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: *

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When 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 *

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May 2022

When 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 *

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June 2022

When 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 *

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July 2022

Describe community event to be held: *

County of community: *

Event is planned to be: *

Indoor
Outdoor

If outdoor, please detail your inclement weather plan.:

Do you have an event venue in mind? *

If yes, please list:

Does the venue have electricity hookups?

Does the venue have the ability to park a semi-truck on-site?

Anticipated 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? *

Do you have nursing staff available to administer testing?

Nursing staff is:

Paid
Volunteer

What 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? *

Planning Details

Please 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? *

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Do you have an established relationship with your local county health department? *

If 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? *

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Please upload your 2022 W9: *

Click or drag a file to this area to upload.