Ohio Collaborative to Prevent Infant Mortality (OCPIM) - Community Change Agent Interest Questionnaire

Please submit by April 11, 2022

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* 1. Personal Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

County

Email Address

Phone Number

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* 2. To what degree do you feel your lived experience has prepared you to become a community change agent?

A great deal

A lot

A moderate amount

A little

None at all

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* 3. Please, rank the following traits you feel are the most important to have working as a change agent.

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* 4. What is the infant mortality rate in the county you live in?

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* 5. How familiar are you with the term birth equity?

Extremely familiar

Very familiar

Somewhat familiar

Not so familiar

Not at all familiar

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* 6. How familiar are you with the term reproductive justice?

Extremely familiar

Very familiar

Somewhat familiar

Not so familiar

Not at all familiar

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* 7. To what degree does racism contribute to Black babies dying?

A great deal

A lot

A moderate amount

A little

None at all

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* 8. Have you advocated for others as a result of unfair treatment?

Yes

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* 9. Would you be willing to work six hours per month for five months, as a community change agent, to build awareness and engage communities to improve pregnancy and infant health?

Yes

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* 10. Please, describe your experience and interest in working with people from diverse backgrounds (including race, culture, gender, sexual orientation, religion, socioeconomics, age, etc.).