Assessment of Strategies for Asthma Control

The California Department of Public Health’s state asthma program, California Breathing, in partnership with Regional Asthma Management and Prevention (RAMP), is working with partners to develop a Strategic Plan for Asthma Control for California. We are sending this survey to clinical providers, health care organizations, local health departments, managed care organizations, community-based organizations, and others to assess the current strategies for asthma control in your geographic area. The survey will take approximately 15 minutes of your time and your input will be very helpful to us. Please have one person answer for your organization as a whole. Results from this assessment will inform strategies to improve asthma control across California communities. We will share the results of this assessment with you once it's complete.

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* 1. Name:

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* 2. Email:

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* 3. Organization name:

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* 4. Type of organization:

Clinic, hospital, or other health care organization

State, county, or local government agency

Managed care organization

Community-based organization

Non-governmental organization

Private individual

Other (please specify)

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* 5. In what county is your organization located?

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* 6. Check the box for the primary and secondary populations that your organization serves:

	Primary population served	Secondary population served
0-5 years	0-5 years Primary population served	0-5 years Secondary population served
6-17 years	6-17 years Primary population served	6-17 years Secondary population served
18-64 years	18-64 years Primary population served	18-64 years Secondary population served
65+	65+ Primary population served	65+ Secondary population served

Comments:

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* 7. Does your organization provide medical/clinical services to patients/clients with asthma?

Yes