State and Territory Survey

Form Approved
OMB No. 0990-XXXX
Exp. Date XX/XX/20XX

ATTACHMENT B

OFFICE OF MINORITY HEALTH

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

STATE AND TERRITORIAL HEALTH DISPARITIES SURVEY

ADVANCE MATERIALS

2015 State and Territorial Health Disparities Survey

Survey Topics for Discussion

• Program Goals and Activities

  • Strategic plan

  • Other planning documents

  • Major strategies to reduce health disparities and advance health equity

  • Setting of priorities

• Partnerships

  • Primary partners

  • Types of collaboration

• Organizational Structure

  • Structure within the state or territory

  • Distribution of responsibility

  • Staffing

• Funding

  • Sources of funding

  • Amounts of funding

  • Total 2014 funding

Thank you for your assistance in gathering this important information and helping the Office of Minority Health at the U.S. Department of Health and Human Services to better understand how {state/territory} addresses minority health, health disparities, and health equity.

Public reporting burden for this collection of information is estimated to average 90 minutes per response, which includes the estimated time required to complete the telephone interview and data collection tables. 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.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Sherette Funn at [email protected], or call the Reports Clearance Office at (202) 690–6162.

2015 State and Territorial Health Disparities Survey

We look forward to speaking with you regarding initiatives in {state/territory} to reduce health disparities, achieve health equity and ultimately improve minority health. To make the call most efficient, please take a few moments to complete the tables below prior to the telephone survey. You may add rows as necessary to these tables.

Completed tables can be sent to [email protected]

1. Describe the staff who are hired or spend some portion of their work time on minority health/health disparities/health equity in {state/territory}? Include part time staff.

Staff Member Title/Role	Primary Department/ Division/Agency	Secondary Department/ Division/Agency	% Time Working on Minority Health Initiatives
Senior Staff
E.g.: Program Director	Office of Minority Health	N/A	75%
Mid-Level Staff
E.g.: Program Coordinator	Office of Minority Health	Mental Health/ Substance Abuse	100%
Other Staff

2. Describe the primary sources of funding for minority health, health disparities, and health equity in {state/territory} for Fiscal Year 2014. Include the total funding for the fiscal year 2014.

Source	Type: State, Federal, Other	On-going or One-time	Amount	Comments
E.g.: State of XX	State	On-going	$500,000	State funding has been consistent at this level for 3 years.
Total funding for FY 2014			$

3. Describe funding for minority health etc., that your state/territory provides to other governmental or nongovernmental entities for FY 2014.

1