Thank you for completing the Disparities in Action toolkit. Please complete the following attestation and polling questions to ensure credit for your work.

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* 1. Please enter your facility name.

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* 2. Please enter your 6-digit CMS certification facility provider number  (begins with 45 or 67).

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* 3. Please enter your first and last name.

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* 4. This tool helped me identify the vulnerable population(s) and health disparities within my facility.

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* 5. This tool helped me identify SMART aims.

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* 6. This tool helped me identify key system elements (Primary Drivers) necessary to achieve my aim(s).

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* 7. This tool helped me identify activities or interventions (Secondary Drivers) to make progress.

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* 8. This tool helped me develop an action plan.

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* 9. This tool helped me provide culturally competent & accessible services for my disparate population.

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* 10. This tool helped me define metrics to monitor progress and assess impact toward my aim(s).

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* 11. This tool helped me document measureable outcomes & actual impact.

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* 12. Do you have any additional questions, concerns or comments?

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