1.Name of Your Organization

2.Name and Title of Person Completing Form

3.How many members from your team will be participaing in the planned sessions?

4.Perceived Value in Participating in the Collaborative?

Aligns with Current Priorities

Need to Gain New Information & Processes

Learning of Best Practices from the Field

Seeking to Explore Practice Innovation

5.What Staff In Your Organization Will Be Committed to the Entire Project

C-Suite Member(s)

QI Team Member(s)

Governing Board Member(s)

Outreach or Community Health Workers

6.Are you able to allow time commitment of representatives referenced above for each session?

Yes

No

7.Are you familiar with HRSA's Health Center Excellence Framework?

Yes

No

Other (somewhat)

8.Which among the 7 HRSA Domains Would Be of Most Interest in An Organizational Audit to Assess Your Efforts Towards Equity?

Governance & Management: Governance, Leadership, ManagementWorkforce: Recruitment, Employee Development or Engagement, Retention, Strategic ManagementFinancial Sustainability:  Liquidity, Solvency, Sufficient Profitability, Financial AgilityPopulation Health & SDOH: Population Needs Assessment, Resource Mapping,Community partnerships & collaboration, Track & Close Social Service Referral LoopsAccess & Affordability: Comprehensive & Timely Services, Affordabiity, Enabling Services, Community OutreachPatient Experience:  Patien Activation & Engagement, Partnership w/Families & Caregivers, Trusting Relationships, Patient-Centered Care CoordinationQuality, Patient Care, and Safety:  Clinical Effectiveness, Cotinuity of Care, Safety, Equity