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

Organization Details - Step 1 of 5

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: *

United States+1
United Kingdom+44
Afghanistan+93
Albania+355
Algeria+213
American Samoa+1
Andorra+376
Angola+244
Anguilla+1
Antigua & Barbuda+1
Argentina+54
Armenia+374
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Ascension Island+247
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Austria+43
Azerbaijan+994
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Bahrain+973
Bangladesh+880
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Belize+501
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Congo - Kinshasa+243
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Croatia+385
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Curaçao+599
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Dominican Republic+1
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El Salvador+503
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Ethiopia+251
Falkland Islands+500
Faroe Islands+298
Fiji+679
Finland+358
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French Guiana+594
French Polynesia+689
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Gambia+220
Georgia+995
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Ghana+233
Gibraltar+350
Greece+30
Greenland+299
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Indonesia+62
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Italy+39
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Jordan+962
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Latvia+371
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Lesotho+266
Liberia+231
Libya+218
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Malaysia+60
Maldives+960
Mali+223
Malta+356
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Martinique+596
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Mayotte+262
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Micronesia+691
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Monaco+377
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Montserrat+1
Morocco+212
Mozambique+258
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Namibia+264
Nauru+674
Nepal+977
Netherlands+31
New Caledonia+687
New Zealand+64
Nicaragua+505
Niger+227
Nigeria+234
Niue+683
Norfolk Island+672
North Korea+850
North Macedonia+389
Northern Mariana Islands+1
Norway+47
Oman+968
Pakistan+92
Palau+680
Palestinian Territories+970
Panama+507
Papua New Guinea+675
Paraguay+595
Peru+51
Philippines+63
Poland+48
Portugal+351
Puerto Rico+1
Qatar+974
Romania+40
Russia+7
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Réunion+262
Samoa+685
San Marino+378
Saudi Arabia+966
Senegal+221
Serbia+381
Seychelles+248
Sierra Leone+232
Singapore+65
Sint Maarten+1
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Slovenia+386
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Somalia+252
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St. Barthélemy+590
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St. Kitts & Nevis+1
St. Lucia+1
St. Martin+590
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Suriname+597
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Sweden+46
Switzerland+41
Syria+963
São Tomé & Príncipe+239
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Tajikistan+992
Tanzania+255
Thailand+66
Timor-Leste+670
Togo+228
Tokelau+690
Tonga+676
Trinidad & Tobago+1
Tunisia+216
Turkey+90
Turkmenistan+993
Turks & Caicos Islands+1
Tuvalu+688
U.S. Virgin Islands+1
Uganda+256
Ukraine+380
United Arab Emirates+971
United Kingdom+44
United States+1
Uruguay+598
Uzbekistan+998
Vanuatu+678
Vatican City+39
Venezuela+58
Vietnam+84
Wallis & Futuna+681
Western Sahara+212
Yemen+967
Zambia+260
Zimbabwe+263
Åland Islands+358

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 *

Rate 1 out of 3Rate 2 out of 3Rate 3 out of 3

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 *

Rate 1 out of 3Rate 2 out of 3Rate 3 out of 3

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 *

Rate 1 out of 3Rate 2 out of 3Rate 3 out of 3

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.

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