CHIO Recertification Please enable JavaScript in your browser to complete this form.Name of Organization *PHIO Board Reviewer *Date (MM/DD/YEAR) *This organization is applying to be:chioCHIOCHIO+The organization indicates that it is:An independent non-profit (e.g. 501c3Will establish an affiliation agreement with the PHIO or;Is affiliated with a non-profit partner that meets all of the other criteria.The organization’s mission statement includes wording that implies improving the health of and health care services available to all citizens of the geographic area served.MetNot MetMore info neededThis organization has a Governing Board that meets regularly and provides support to the organizationMetNot MetThis organization has a Youth Board that meets regularly and provides support to the organization MetNot MetThis organization has volunteers that meets regularly and provides support to the organizationMetNot MetDoes this organization provide compensation, childcare, or meals to support community members participating in your activities? YesNoDoes the service delivery and area of practice align with the goals of PHIO ?MetNot MetDoes this organization participate in Community Health Plans or Community Health Needs Activities? MetNot MetDo the organization's top three health goals align with the goals of PHIO?MetNot MetDo the organization's community education events align the goals of PHIO?MetNot MetIs the organization representative of several sectors of health improvement activities? MetNot MetDoes the organization haves strong partners in their community? MetNot MetDoes the organization have health care providers involved in their health improvement efforts?MetNot MetApplication submitted with the following supporting materials: *By-Laws/ProceduresCover LetterBOD ListLetters of Support (2 min)Necessary supporting materials provided. *MetNot MetMore RequestedThe established set of policies and procedures that define a process for deciding upon and prioritizing acceptance of and distribution of resources/funds is working for the organization. *MetNot MetNeed more infoThe organization has a plan to develop the capacity to recruit and supervise community volunteers (this may also be reflected in organization’s by-laws and or procedures). *MetNot MetNeed more infoThe organization has a clearly stated sustainability plan. *MetNot MetNeed more infoComments & Recommendations *Overall: *Approve this CHIO for re-certificationDo not approve this CHIO for re-certificationPending additional infoPhoneSubmit
