RDIM Community of Practice Survey Interest Form


Please complete the survey by Friday, May 29, 2020. Your complete responses to the survey confirm your interest to participate in the RDIM community of practice. Entry into the CoP will be on a first come first serve basis. The earlier you submit your completed survey, the more likely you will be accepted into the CoP. We will review all survey submissions and email confirmations shortly thereafter.
If you should have questions or need further information, please contact your Hub Lead or send an email to ncitinfo@buildinitiative.org. 

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* 1. Full Name (First, Last)

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* 2. In what state or U.S. territory do you currently work?

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* 3. Are you a member of a prenatal-to-three state coalition? If yes, please provide the name of the coalition. 

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* 4. What are your goals for participating in the Racial Disparities in Infant and Maternal Morbidity and Mortality Community of Practice?  Select all that apply. (You may choose more than one option, including "unsure at this moment," or "other reasons;" if you have chosen "other reasons," please explain in Question #4.)

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* 5. If you chose “Other,” please explain. 

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* 6. What is your entire team’s level of engagement on eliminating racial disparities in maternal and infant mortality?

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* 7. Has your team identified wins/successes regarding this topic?

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* 8. If you answered “yes” in Question #6, please share your successes here.

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* 9. What have been your obstacles or challenges regarding this topic?

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* 10. How confident are you in your state’s current capacity to (Use a scale from 1 to 4 with 1=no confidence; 2=slight confidence; 3=moderate confidence and 4=high confidence):

  No Confidence (1) Slight Confidence (2) Moderate Confidence (3) High Confidence (4)
1. Produce disaggregated data (for example, ethnicity, country of origin, and primary language) related to maternal and infant morbidity and mortality at the state level.
2. Produce disaggregated data (for example, ethnicity, country of origin, and primary language) related to maternal and infant morbidity and mortality at the community or county level.
3.  Use data for storytelling.
4. Connect with or identify strategies to bring family and provider voice into the data interpretation, root causes analysis, and strategy planning.
5.  Use data and the application of a critical race theory lens to select appropriate and effective interventions. 
6. Identify existing programs, policies, initiatives, and champions related to maternal and infant health.
7. Identify existing programs, policies, initiatives, and champions working to identify root causes and make changes to address racial disparities in maternal and infant morbidity and mortality.
8. Identify the root causes of racial disparities in maternal and infant morbidity and mortality.
9. Evaluate existing state and local public policy, dedicated funding, access to programs and services, and general awareness of the racial disparities in maternal and infant morbidity and mortality.
10. Identify who must be at the table (departments, organizations, etc.) to address racial disparities in maternal and infant morbidity and mortality?
11. Identify existing system strengths and barriers.  
12. Identify pivotal system changes that need to be made within states and communities to ensure better infant and maternal outcomes.

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* 11. Please rank the importance of the following strategies for eliminating racial disparities in maternal and child health in your state PN-3 work. (Use a scale from 1 to 4 with 1=not important at all; 2=not very important; 3=somewhat important and 4=very important):

  Not Important at All (1) Not Very Important (2) Somewhat Important  (3) Very Important (4)
1. Produce disaggregated data (for example, ethnicity, country of origin, and primary language) related to maternal and infant morbidity and mortality at the state level.
2. Produce disaggregated data (for example, ethnicity, country of origin, and primary language) related to maternal and infant morbidity and mortality at the community or county level.
3.  Use data for storytelling.
4. Connect with or identify strategies to bring family and provider voice into the data interpretation, root causes analysis, and strategy planning.
5.  Use data and the application of a critical race theory lens to select appropriate and effective interventions. 
6. Identify existing programs, policies, initiatives, and champions related to maternal and infant health.
7. Identify existing programs, policies, initiatives, and champions working to identify root causes and make changes to address racial disparities in maternal and infant morbidity and mortality.
8. Identify the root causes of racial disparities in maternal and infant morbidity and mortality.
9. Evaluate existing state and local public policy, dedicated funding, access to programs and services, and general awareness of the racial disparities in maternal and infant morbidity and mortality.
10. Identify who must be at the table (departments, organizations, etc.) to address racial disparities in maternal and infant morbidity and mortality?
11. Identify existing system strengths and barriers.  
12. Identify pivotal system changes that need to be made within states and communities to ensure better infant and maternal outcomes.

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* 12. Are there experts with whom you would like to connect to elevate your PN-3 work on this topic?

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* 13. Other topics or questions you would like discussed throughout the duration of the community of practice: 

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