Ohio Collaborative to Prevent Infant Mortality (OCPIM) 2025 Regional Membership Application

What is your region?

The information that you provide will be used by your regional leadership council members to contact you regarding future meetings and to provide you with additional information.

Please review the OCPIM regional map to determine your region.

Question Title

* 1. What region do you represent based on the OCPIM regional map?

Northwest

Northeast

Central

Southwest

Southeast

Statewide

Question Title

* 2. Are there efforts in your region focused on reducing infant mortality?

Yes

Don't know

Question Title

* 3. If yes, please list the efforts in your region that are focused on reducing infant mortality. If no, enter N/A.

Question Title

* 4. Are you involved in any efforts related to maternal and child health?

Yes

Not sure

Question Title

* 5. Which format would you prefer for regional meetings?

Conference call

Video conference

In person

Combination of the above

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* 6. Please rank the four OCPIM priority areas based on your community's needs.

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* 7. List up to three primary concerns that should guide your region's efforts to eliminate disparities in infant mortality—for example, transportation.

Concern 1:

Concern 2:

Concern 3:

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* 8. By completing the following, you agree to be an active and contributing member of OCPIM.

Name

Title

Organization

Question Title

* 9. Provide your contact information.

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

County

Email Address

Phone Number

Ohio Collaborative to Prevent Infant Mortality (OCPIM) 2025 Regional Membership Application

What is your region?

Question Title

* 1. What region do you represent based on the OCPIM regional map?

Question Title

* 2. Are there efforts in your region focused on reducing infant mortality?

Question Title

* 3. If yes, please list the efforts in your region that are focused on reducing infant mortality. If no, enter N/A.

Question Title

* 4. Are you involved in any efforts related to maternal and child health?

Question Title

* 5. Which format would you prefer for regional meetings?

Question Title

* 6. Please rank the four OCPIM priority areas based on your community's needs.

Question Title

* 7. List up to three primary concerns that should guide your region's efforts to eliminate disparities in infant mortality—for example, transportation.

Question Title

* 8. By completing the following, you agree to be an active and contributing member of OCPIM.

Question Title

* 9. Provide your contact information.

Question Title

* 10. We welcome further comments or questions here.