Form instrument #1 instrument #1 HBCU Survey

OMB No. 0000-0000: Approval Expires 00/00/0000

American Institutes for Research Acting as collecting agent for U.S. Department of Health and Human Services Health Resources and Services Administration Office of Minority Health Survey of HBCU Administrators 2006 Survey of the Engagement of Historically Black Colleges and Universities In Activities to Reduce Health Disparities	Public Burden Statement:  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0915_xxxx.  Public reporting burden for this collection of information is estimated to average 45 minutes for the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.
survey explanation This survey is being conducted on behalf of the U.S. HHS/HRSA Office of Minority Health to determine the types of activities that HBCUs have implemented to eliminate racial and ethnic health disparities among their student populations and in their surrounding communities. The results of this survey will be used by the Office of Minority Health (OMH) to educate the public about the role that HBCUs play in eliminating racial and ethnic health disparities and to determine ways in which OMH can help HBCUs to expand their role and effectiveness in addressing health disparities. The information provided by HBCUs and their representatives will be used solely for statistical and reporting purposes. No information collected in this survey may be used for any purpose other than the purpose for which it has been collected. Such information may not be published or released in any form if the individual responding to the survey or the institution is identifiable, unless the individual or institution has consented to such release. Presidents of HBCUs, as well as, Deans, Administrators, and other personnel at HBCUs who are familiar with the types of activities that institutions have designed to reduce health disparities have been asked to participate in this survey. Although your participation is voluntary and there are no penalties for refusing to answer any questions, it is essential that we obtain data from every HBCU. Your participation is greatly appreciated.
Section A – INSTITUtION AND ROLE IDENTIFICATION
Institution Identification Please enter the name of your institution below.
What is your primary role at this institution? Mark (X) only ONE box.		University or College President (Go to Section B) Dean of Faculty (Go to Section C) Dean of Students (Go to Section C) Director of Student Health (Go to Section C) Other (specify below):

Section B – QUESTIONS FOR HBCU PRESIDENTS
3a. Have you set an explicit mission or agenda to engage in campus-based or community activities designed to eliminate health disparities? For example, have you stated to the Board, Faculty, or Alumni that you believe that the college should be involved in activities to reduce health disparities?	No (Go to 3b) Yes (Go to 3c)
3b. Why have you not set an explicit mission to engage in activities to reduce health disparities?	Write your response below: GO TO QUESTION 4
3c. When was the mission established?	Specify Year:
3d. Why did you decide that your institution should be engaged in activities designed to eliminate health disparities among students or within the community?	Write your response below:
3 e. What mechanisms have you used to convey your institutional mission to eliminate health disparities to members of the University/College Board of Trustees?	Check all that apply: At Board Meetings Through written memos and documents At public addresses Other (specify below):
3f. What mechanisms have you used to convey your institutional mission to eliminate health disparities to faculty?	Check all that apply: At faculty meetings Through written memos and documents At public addresses By establishing university-wide initiatives designed to encourage faculty to design activities or research focused on the elimination of health disparities Other (specify below):
3g. What mechanisms have you used to convey your institutional mission to eliminate health disparities to students?	Check all that apply: Through written memos and documents At public addresses By establishing university-wide initiatives designed to encourage students to design activities or research focused on the elimination of health disparities Other (specify below):
4a. Do you feel that you are able to provide us with the details about the types of campus and community-based activities that this HBCU has undertaken or is there someone else on campus who would be better suited to provide us with detailed information?	No, someone else would be better suited (Go to 4b) Yes (Go to 5a)
4b. What is the name (or names) and contact information for the person (s) on campus who can provide the best information about activities related to health disparities?	Person 1 Name: Person 1 Contact Information: Person 2 Name: Person 2 Contact Information: END SURVEY/INTERVIEW
5a. Are faculty members encouraged by the university or their department chairs to conduct research focusing on health disparities?	No (Go to 6a) Yes (Go to 5b)
5b. What mechanisms are in place to encourage faculty to conduct research specifically on issues related to eliminating racial and ethnic health disparities?	Check all that apply: Special university-sponsored faculty research awards Collaborations with other institutions of higher education Established a Health Disparities Research Center on campus Other: Don’t Know

6a. Are faculty members encouraged by the university or their department chairs to incorporate topics related to health disparities in their courses?	No (Go to question 7a) Yes (Go to 6b)
6 b. What resources are provided by the university to permit faculty to develop curricula focused on health disparities?	Check all that apply: Reduced course-load during semester when new curricula are being developed University-sponsored course development grants Other:
7a. Have university/college faculty developed and/or implemented any programs focusing on health disparities to serve the campus-based students or university personnel?	No (Go to 8a) Yes (Go to 7b)
7b. What campus populations are served by these campus-based programs?	Check all that apply: Undergraduate Students Graduate Students HBCU Faculty and Administrators University support staff Other:
7c. What health areas are most commonly addressed by these faculty-developed campus-based programs?	Check all that apply: Smoking cessation Pregnancy prevention Safe sex (including STD/HIV/AIDS prevention) Date rape Diabetes care Heart disease prevention Obesity prevention and exercise Depression and mental health Maternal and child health Sickle cell Asthma and other respiratory illnesses Cancer Smoking Other:

7d. Please describe at least ONE faculty-developed campus-based health disparities program that has been implemented on your campus. (Describe health area that is the focus of the project, target audience for program, and overall program operations)	Write your response below:
8a. Are faculty members encouraged by the university or their department chairs to develop community-based education and service programs focused on eliminating ethnic/racial health disparities?	No (Go to 9a) Yes (Go to 8b)
8b. What resources are available to encourage faculty to develop community-based programs focused on eliminating racial and ethnic health disparities?	Check all that apply: Special university-sponsored faculty service awards Collaborations with other institutions of higher education Collaborations with community-agencies Established a Health Disparities Research Center on campus Other: Don’t Know
9a. Have university/college faculty developed and/or implemented any programs focusing on health disparities to serve the community surrounding the university?	No (Go to 10a) Yes (Go to 9b)
9b. What populations are served by these faculty-developed community-based programs?	Check all that apply: School-aged children (Grades K-8) Adolescents Mothers of young children Elderly African-American women African-American men Other specific community-based populations:

9c. What health areas are most commonly addressed by these faculty-developed community-based programs?	Check all that apply: Smoking cessation Pregnancy prevention Safe sex (including STD/HIV/AIDS prevention) Date rape Diabetes care Heart disease prevention Obesity prevention and exercise Depression and mental health Maternal and child health Sickle cell Asthma and other respiratory illnesses Cancer Other:
9d. Please describe at least ONE faculty-developed community-based health disparitiesprogram. (Describe health area that is the focus of the project, target audience for program, and overall program operations)
10a. Are faculty members encouraged by the university or their department chairs to develop community-based education and service programs focused on eliminating ethnic/racial health disparities?	No (Go to 11a) Yes (Go to 10b)
10b. What resources are available to encourage faculty to develop community-based programs focused on eliminating racial and ethnic health disparities?	Check all that apply: Special university-sponsored faculty service awards Collaborations with other institutions of higher education Collaborations with community-agencies Established a Health Disparities Research Center on campus Other:
11. What mechanisms have been most successful in encouraging faculty to engage in activities designed to eliminate racial and ethnic health disparities?	Write answer below.

12a. Are there currently any student-operated campus or community-based health disparities service programs that are sponsored by the university or organizations within the university/college?	No (Go to 13a) Yes (Go to 12b)
12b. What campus or community populations are served by these student-operated programs?	Check all that apply: Other undergraduate or graduate students on campus School-aged children (Grades K-8) Adolescents Mothers of young children Elderly African-American women African-American men Other specific community-based populations:
12c. What health areas are most commonly addressed by these student-operated programs?	Check all that apply: Smoking cessation Pregnancy prevention Safe sex (including STD/HIV/AIDS prevention) Date rape Diabetes care Heart disease prevention Obesity prevention and exercise Depression and mental health Maternal and child health Sickle cell Asthma and other respiratory illnesses Cancer Other:
12d. Please describe at least ONE student-operated campus or community-based health disparities program that originated on your campus. (Describe health area that is the focus of the project, target audience for program, and overall program operations)

13a. Are students encouraged by the university administrators or faculty to develop campus or community-based service programs focused on eliminating ethnic/racial health disparities?	No (Go to 14a) Yes (Go to 13b)
13b. What resources are available to encourage students to develop campus or community-based programs focused on eliminating racial and ethnic health disparities?	Check all that apply: Special university-sponsored student service awards Special university funding opportunities for student organizations Fraternity or sorority funding Other:
14. What mechanisms have been most successful in encouraging students to engage in activities designed to eliminate racial and ethnic health disparities?	Write answer below.
15. What resources would you need in order to increase your institution’s engagement in campus and community-based activities designed to decrease ethnic/racila health disparities?	Check all that apply: Additional funding Technical support including information on how to establish such programs Examples of programs established at other HBCUs Other:

Section C – QUESTIONS FOR HBCU DEANS AND ADMINISTRATORS
3a. Has the university/college President set an explicit mission or agenda to engage in campus-based or community activities designed to eliminate health disparities? For example, has he/she stated to the Board, Faculty, or Alumni they believe that the college should be involved in activities to reduce health disparities?	No (Go to 4a) Yes (Go to 3c)
3b. When was the mission established?	Specify Year:
4a. Are faculty members encouraged by university administrators or their department chairs to conduct research focusing on health disparities?	No (Go to 5a) Yes (Go to 4b)
4 b. What mechanisms are in place to encourage faculty to conduct research specifically on issues related to eliminating racial and ethnic health disparities?	Check all that apply: Special university-sponsored faculty research awards Collaborations with other institutions of higher education Established a Health Disparities Research Center on campus Other: Don’t Know
5a. Are faculty members encouraged by university administrators and their department chairs to incorporate topics related to health disparities in their courses?	No (Go to question 6a) Yes (Go to question 5b)
5 b. What resources are provided by the university to permit faculty to develop curricula focused on health disparities?	Check all that apply: Reduced course-load during semester when new curricula are being developed University-sponsored course development grants Other:

6a. Have university/college faculty developed and/or implemented any programs focusing on health disparities to serve the campus community?	No (Go to 7a) Yes (Go to 6b)
6b. What campus populations are served by these faculty-developed campus-based programs?	Check all that apply: Undergraduate Students Graduate Students HBCU Faculty and Administrators University support staff Other:
6c. What health areas are most commonly addressed by these faculty-developed campus-based programs?	Check all that apply: Smoking cessation Pregnancy prevention Safe sex (including STD/HIV/AIDS prevention) Date rape Diabetes care Heart disease prevention Obesity prevention and exercise Depression and mental health Maternal and child health Sickle cell Asthma and other respiratory illnesses Cancer Other:

7a. Are faculty members encouraged by university administrators or department chairs to develop campus-based education and service programs focused on eliminating ethnic/racial health disparities?	No (Go to 8a) Yes (Go to 7b)
7b. What resources are available to encourage faculty to develop campus-based programs focused on eliminating racial and ethnic health disparities?	Check all that apply: Special university-sponsored faculty service awards Collaborations with other institutions of higher education Collaborations with community-agencies Established a Health Disparities Research Center on campus Other: Don’t Know
8a. Have university/college faculty developed and/or implemented any programs focusing on health disparities to serve the community that surrounds the university campus?	No (Go to 9) Yes (Go to 8b)
8b. What populations are served by these faculty-developed community-based programs?	Check all that apply: School-aged children (Grades K-8) Adolescents Mothers of young children Elderly African-American women African-American men Other specific community-based populations:

8c. What health areas are most commonly addressed by these community-based programs?	Check all that apply: Smoking cessation Pregnancy prevention Safe sex (including STD/HIV/AIDS prevention) Date rape Diabetes care Heart disease prevention Obesity prevention and exercise Depression and mental health Maternal and child health Sickle cell Asthma and other respiratory illnesses Cancer Other:
8d. Please describe at least ONE faculty-developed community-based health disparities program. (Describe health area that is the focus of the project, target audience for program, and overall program operations)
9a. Are faculty members encouraged by university administrators or department chairs to develop community-based education and service programs focused on eliminating ethnic/racial health disparities?	No (Go to 10) Yes (Go to 9b)
9b. What resources are available to encourage faculty to develop community-based programs focused on eliminating racial and ethnic health disparities?	Check all that apply: Special university-sponsored faculty service awards Collaborations with other institutions of higher education Collaborations with community-agencies Established a Health Disparities Research Center on campus Other:

10. What mechanisms have been most successful in encouraging faculty to engage in activities designed to eliminate racial and ethnic health disparities?	Write answer below.
11a. Are there currently any student-operated campus or community-based health disparities service programs on sponsored by the university or organizations within the university/college?	No (Go to 12a) Yes (Go to 11b)
11b. What campus or community populations are served by these student-operated programs?	Check all that apply: Other undergraduate or graduate students on campus School-aged children (Grades K-8) Adolescents Mothers of young children Elderly African-American women African-American men Other specific community-based populations:
11c. What health areas are most commonly addressed by these programs?	Check all that apply: Smoking cessation Pregnancy prevention Safe sex (including STD/HIV/AIDS prevention) Date rape Diabetes care Heart disease prevention Obesity prevention and exercise Depression and mental health Maternal and child health Sickle cell Asthma and other respiratory illnesses Cancer Other:
11d. Please describe at least ONE student-operated campus or community-based health dispariteis program that originated on your campus. (Describe health area that is the focus of the project, target audience for program, and overall program operations)

12a. Are students encouraged by university administrators and faculty to develop campus or community-based service programs focused on eliminating ethnic/racial health disparities?	No (Go to 13) Yes (Go to 12b)
12b. What resources are available to encourage students to develop campus or community-based programs focused on eliminating racial and ethnic health disparities?	Check all that apply: Special university-sponsored student service awards Special university funding opportunities for student organizations Fraternity or sorority funding Other:
13. What mechanisms have been most successful in encouraging students to engage in activities designed to eliminate racial and ethnic health disparities?	Write answer below.
14. What resources would you need in order to increase your institution’s engagement in campus and community-based activities designed to decrease ethnic/racila health disparities?	Check all that apply: Additional funding Technical support including information on how to establish such programs Examples of programs established at other HBCUs Other: