Birthing Cultural Rigor (BCR)
Client Intake Form

Section 1: Organizational Information

Thank you for your taking the first step to transforming your organization. Prior to scheduling a FREE 40 minute exploratory meeting with Dr. Karen A. Scott, MD, MPH, FACOG, BCR Chief Black Feminist Physician Scientist, Founding CEO, and Owner, we require you complete the client intake form. The purpose of the form is learn more about your organization's readiness to address obstetric racism as a never event that violates obstetric quality and patient safety.

The survey includes 27 different types of questions. The estimated survey completion time is 15 minutes. You can follow your progress at the bottom of the page.

Thank you for your interest in our products and services.

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1. What is today's date? (Required.)

Date / Time

Date

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2. First Name (Required.)

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3. Last Name (Required.)

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4. Email address (Required.)

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5. Pronouns (Required.)

She/Her/Hers

He/Him/His

They/Them/Their

Other (please specify)

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6. Contact Phone Number (xxx) xxx-xxxx (Required.)

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7. Credentials (MPH, MD, RN, PhD, EdD, etc)

(Required.)

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8. Organization Name (Required.)

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9. Is your organization a hospital, health system, or health center that provides services and/or supports to Black women, girls, and gender expansive people experiencing ANY pregnancy related condition (e.g., termination, labor, birth, postpartum, lactation, perinatal mental health) (Required.)

Yes

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10. Your Title/Role within the Organization (Required.)

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11. Organization Type (Required.)

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12. Organization City (Required.)

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13. Organization State (Required.)

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14. In 5 sentences or less, briefly explain the most pressing issues your organization needs to address over the next 2 years. (Required.)

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15. In 5 sentences or less, briefly explain how do you imagine BCR facilitating your highest levels of impact in addressing the issues described in the previous question (Q14). (Required.)

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16. What type of services do you seek? (Check all that apply). (Required.)

Health Services Assessment & Evaluation

Interprofessional Education & Training

Re-Design of Health Services Provision

Measurement Selection, Monitoring, and Utilization

Building Dignified Community Partnerships in Quality Improvement

Patient Experiential Data Collection

Community Experiential Data Collection

Provider/Staff Experiential Data Collection

Other (please specify)

Question Title

17. Why are you seeking support from our firm? (Check all that apply). (Required.)

Lack of training with a complementary impact evaluation on addressing obstetric racism during service provision to Black women, Black girls and Black gender expansive people.

Lack of crisis communication/response to informal and formal grievances/complaints from Black women, Black girls and Black gender expansive people about quality and patient safety

Lack of reliable, responsive and rigorous data about the experiences and outcomes of Black women, Black girls and Black gender expansive people.

Lack of Black patient/public trust and participation in your improvement or implementation initiatives

Lack of expertise from public health, social sciences, humanities, ethics, or community organizing/advocacy on your improvement or implementation initiative.

Undesirable media attention from a maternal or perinatal death or life-threatening complication involving a Black woman, Black girl or Black gender expansive person

Other (please specify)

Question Title

18. What are your organizational quality and patient safety pain points in addressing the epidemic of obstetric racism that disproportionately impacts Black women, girls, and gender expansive people ? (Check all that apply). (Required.)

Data (quality, accessibility, integration and dissemination)

Ethics and Political (organizational and team ethics and political will)

Leadership (diversity, equity, inclusion, belonging and/or justice)

Knowledge (team leadership and staff)

Community Participation and Partnerships

Science (theories, methods, and methodologies)

Measurement Strategies (Selection, Interpretation, and Monitoring)

Resources including funding and experts in anti-Black racism, anti-Black misogynoir (anti-Black woman racism + sexism + other oppressions), obstetric racism (medical racism + obstetric violence), social sciences, public health, legal studies, etc.

Other (please specify)

Question Title

19. What immediate actions do you need your institution to implement to address the epidemic of obstetric racism? [Rank in order of importance: highest (1) and lowest (6)].

Problem recognition and strategic vision

N/A

Activation of community leadership with funding

N/A

Truth, healing, & recognition with Black women and people

N/A

Funding and training of administration, clinicians, and staff in QI or ImpSci

N/A

Data collection, analysis, synthesis, and dissemination in health services and utilization

N/A

Courageous, compassionate, and comfortable conversations about the presence and permeation of obstetric racism with patient, community, and hospital stakeholders

N/A

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20. What is your desired (and realistic) start date? Please respond from a place of truth, transparency, integrity, and accountability given the (un)favorable conditions of your organization and team. (Required.)

Date / Time

Date

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21. What is your approved budget to enter into a contractual agreement with BCR? Please respond from a place of truth, transparency, integrity, and accountability given the (un)favorable conditions of your organization and team. You will need a minimum of $40,000. Click here to learn more about our services and discounts. (Required.)

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22. What is your desired time commitment for organizational participation in"Diagnosing and Dismantling Obstetric Racism Readiness Assessment"? (3 months is the minimum required time commitment). (Required.)

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23. Have you identified and/or partnered with a Black woman-led community based organization in your city, county, or state to participate in our programs and services? (Required.)

Yes

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24. Based on your prior response to Q23: If you answered "Yes", enter the organization's name, organization's address, and contact lead name, credentials, role/title, and email below in the comment box.

If you answered "No", explain the challenges in identifying a local, state, regional, or national Black community organization. (Required.)

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25. Do you have prior verbal or written enthusiastic approval from your executive leadership to seek support from Birthing Cultural Rigor, LLC? (Required.)

Yes

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26. Do you have prior verbal or written enthusiastic approval from the person(s) responsible for funding the services offered by Birthing Cultural Rigor? (Required.)

Yes

50% of survey complete.

Birthing Cultural Rigor (BCR) Client Intake Form

Section 1: Organizational Information

Question Title

* 1. What is today's date? (Required.)

Question Title

* 2. First Name (Required.)

Question Title

* 3. Last Name (Required.)

Question Title

* 4. Email address (Required.)

Question Title

* 5. Pronouns (Required.)

Question Title

* 6. Contact Phone Number (xxx) xxx-xxxx (Required.)

Question Title

* 7. Credentials (MPH, MD, RN, PhD, EdD, etc) (Required.)

Question Title

* 8. Organization Name﻿﻿ (Required.)

Question Title

* 9. Is your organization a hospital, health system, or health center that provides services and/or supports to Black women, girls, and gender expansive people experiencing ANY pregnancy related condition (e.g., termination, labor, birth, postpartum, lactation, perinatal mental health) (Required.)

Question Title

* 10. Your Title/Role within the Organization (Required.)

Question Title

* 11. Organization Type (Required.)

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* 12. Organization City (Required.)

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* 13. Organization State (Required.)

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* 14. In 5 sentences or less, briefly explain the most pressing issues your organization needs to address over the next 2 years. (Required.)

Question Title

* 15. In 5 sentences or less, briefly explain how do you imagine BCR facilitating your highest levels of impact in addressing the issues described in the previous question (Q14). (Required.)

Question Title

* 16. What type of services do you seek? (Check all that apply). (Required.)

Question Title

* 17. Why are you seeking support from our firm? (Check all that apply). (Required.)

Question Title

* 18. What are your organizational quality and patient safety pain points in addressing the epidemic of obstetric racism that disproportionately impacts Black women, girls, and gender expansive people ? (Check all that apply). (Required.)

Question Title

* 19. What immediate actions do you need your institution to implement to address the epidemic of obstetric racism? [Rank in order of importance: highest (1) and lowest (6)].

Question Title

* 20. What is your desired (and realistic) start date? Please respond from a place of truth, transparency, integrity, and accountability given the (un)favorable conditions of your organization and team. (Required.)

Question Title

Question Title

* 22. What is your desired time commitment for organizational participation in"Diagnosing and Dismantling Obstetric Racism Readiness Assessment"? (3 months is the minimum required time commitment). (Required.)

Question Title

* 23. Have you identified and/or partnered with a Black woman-led community based organization in your city, county, or state to participate in our programs and services? (Required.)

Question Title

Question Title

* 25. Do you have prior verbal or written enthusiastic approval from your executive leadership to seek support from Birthing Cultural Rigor, LLC? (Required.)

Question Title

* 26. Do you have prior verbal or written enthusiastic approval from the person(s) responsible for funding the services offered by Birthing Cultural Rigor? (Required.)

Birthing Cultural Rigor (BCR)
Client Intake Form

1. What is today's date? (Required.)

2. First Name (Required.)

3. Last Name (Required.)

4. Email address (Required.)

5. Pronouns (Required.)

6. Contact Phone Number (xxx) xxx-xxxx (Required.)

7. Credentials (MPH, MD, RN, PhD, EdD, etc)

(Required.)

8. Organization Name (Required.)

9. Is your organization a hospital, health system, or health center that provides services and/or supports to Black women, girls, and gender expansive people experiencing ANY pregnancy related condition (e.g., termination, labor, birth, postpartum, lactation, perinatal mental health) (Required.)

10. Your Title/Role within the Organization (Required.)

11. Organization Type (Required.)

12. Organization City (Required.)

13. Organization State (Required.)

14. In 5 sentences or less, briefly explain the most pressing issues your organization needs to address over the next 2 years. (Required.)

15. In 5 sentences or less, briefly explain how do you imagine BCR facilitating your highest levels of impact in addressing the issues described in the previous question (Q14). (Required.)

16. What type of services do you seek? (Check all that apply). (Required.)

17. Why are you seeking support from our firm? (Check all that apply). (Required.)

18. What are your organizational quality and patient safety pain points in addressing the epidemic of obstetric racism that disproportionately impacts Black women, girls, and gender expansive people ? (Check all that apply). (Required.)

19. What immediate actions do you need your institution to implement to address the epidemic of obstetric racism? [Rank in order of importance: highest (1) and lowest (6)].

20. What is your desired (and realistic) start date? Please respond from a place of truth, transparency, integrity, and accountability given the (un)favorable conditions of your organization and team. (Required.)

22. What is your desired time commitment for organizational participation in"Diagnosing and Dismantling Obstetric Racism Readiness Assessment"? (3 months is the minimum required time commitment). (Required.)

23. Have you identified and/or partnered with a Black woman-led community based organization in your city, county, or state to participate in our programs and services? (Required.)

25. Do you have prior verbal or written enthusiastic approval from your executive leadership to seek support from Birthing Cultural Rigor, LLC? (Required.)

26. Do you have prior verbal or written enthusiastic approval from the person(s) responsible for funding the services offered by Birthing Cultural Rigor? (Required.)