Structural Competency Learning Group Application

Thank you for your interest in the Structural Competency Learning Group. As learning collaboratives work best with a small, consistent group of participants, we are limiting the number of participants
in this cohort. We want to provide a cohesive and positive learning environment where participants get to know each other and share learnings built upon exercises and small group discussions. You can find FAQs for the course here. If you are interested in applying, please fill out the following questions. Applications are due by May 2nd. The dates of the sessions are: May 8 (Kick off call), May 15, 22, 29, June 5th. Thank you!

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* 1. Name as you prefer to be called (First and last)

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* 2. What are your pronouns?

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* 3. Email address

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* 4. City, State

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* 5. Health center name (please write out complete name)

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* 6. Title

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* 7. Which of the following best describes you? (Select all that apply)

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* 8. Beyond race and ethnicity, what other identities would best describe you? (e.g. gender identity, sexual orientation, disability/ability status, etc.)

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* 9. How would you rate your knowledge of the topic of Structural Competency?

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* 10. How would you rate your comfort in engaging in conversations about the following topics:

  Do not feel equipped to engage in conversations Feel somewhat comfortable in engaging in conversations Feel comfortable in engaging in conversations Feel very comfortable in engaging in conversations Feel extremely comfortable in engaging in conversations
White supremacy
Structural racism
Power and privilege
Social drivers of health/SDOH/Vital Conditions
Best practices for an inclusive work culture
Best practices for providing culturally and linguistically appropriate care

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* 11. What tools, policies, or procedures does your organization have to create and sustain a culture of inclusion in your workforce?

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* 12. Describe your role in addressing and improving the culture of your workplace – for your team and for your patients.

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* 13. What data does your organization ask patients about their SDOH/vital conditions/social drivers of health to support care plans?

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* 14. How might you apply the information you get during this Learning Group?

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* 15. What barriers might get in your way to join this learning group and contribute as fully as the commitment requires?

Thank you for your interest! We will be reviewing applications and sending out notifications by April 26th.

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