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

What is your region?

The information that you provide will be used by your regional co-leads 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

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, discrimination.

Concern 1:

Concern 2:

Concern 3:

Question Title

* 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) 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, discrimination.

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.

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