CCHA RAE 3 Advisory Committee Interested Party Survey

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1. Name (Required.)

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2. Email (Required.)

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3. Organization Name (if you are a Health First Colorado Medicaid member, please type in Member) (Required.)

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4. Which Program Improvement Advisory Committee are you interested in? (Required.)

Program Improvement Advisory Committee (PIAC) - Northern Counties
(Boulder, Broomfield, Clear Creek, Gilpin, Jefferson)

Program Improvement Advisory Committee (PIAC) - Southern Counties
(El Paso, Park, Teller)

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5. Are you interested in participating in CCHA's Regional Health Equity Committee?

Yes

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6. Sector Represented (Required.)

Health First Colorado Member

Members' Families and/or Caregiver

Primary Care Medical Provider (PCMP)

Behavioral Health Provider

Specialist Provider

Hospital

Long-Term Services & Supports

Nursing Facility

Oral Health

Advocacy Organization

Community-Based Organization

Local Public Health

Child Welfare Interests

Aging/Elderly/DSNP

Other (please specify)

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7. What population do you represent? (Required.)

Black Indigenous People of Color (BIPOC)

Members with Disabilities

Members Living in Rural Areas

Child and Youth

LGBTQIA+

All Populations

Other (please specify)

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8. Are you interested in collaborating with healthcare providers, other community-based organizations, and Medicaid members to shape regional and state-level initiatives? (Required.)

Yes

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9. What challenges to the communities you serve/live in do you face in accessing and utilizing Medicaid benefits? (Check all that apply) (Required.)

Transportation

Housing

Access to Care/Services

Language

Food Security

Transitions of Care

Other (please specify)

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10. On average, what percentage of individuals that you serve are on Medicaid or potentially eligible but not enrolled? (Required.)

50%

100%

Clear

i We adjusted the number you entered based on the slider’s scale.

CCHA RAE 3 Advisory Committee Interested Party Survey

Question Title

* 1. Name (Required.)

Question Title

* 2. Email (Required.)

Question Title

* 3. Organization Name (if you are a Health First Colorado Medicaid member, please type in Member) (Required.)

Question Title

* 4. Which Program Improvement Advisory Committee are you interested in? (Required.)

Question Title

* 5. Are you interested in participating in CCHA's Regional Health Equity Committee?

Question Title

* 6. Sector Represented (Required.)

Question Title

* 7. What population do you represent? (Required.)

Question Title

* 8. Are you interested in collaborating with healthcare providers, other community-based organizations, and Medicaid members to shape regional and state-level initiatives? (Required.)

Question Title

* 9. What challenges to the communities you serve/live in do you face in accessing and utilizing Medicaid benefits? (Check all that apply) (Required.)

Question Title

* 10. On average, what percentage of individuals that you serve are on Medicaid or potentially eligible but not enrolled? (Required.)

1. Name (Required.)

2. Email (Required.)

3. Organization Name (if you are a Health First Colorado Medicaid member, please type in Member) (Required.)

4. Which Program Improvement Advisory Committee are you interested in? (Required.)

5. Are you interested in participating in CCHA's Regional Health Equity Committee?

6. Sector Represented (Required.)

7. What population do you represent? (Required.)

8. Are you interested in collaborating with healthcare providers, other community-based organizations, and Medicaid members to shape regional and state-level initiatives? (Required.)

9. What challenges to the communities you serve/live in do you face in accessing and utilizing Medicaid benefits? (Check all that apply) (Required.)

10. On average, what percentage of individuals that you serve are on Medicaid or potentially eligible but not enrolled? (Required.)