Key NPA partner organizations

Attachment D: NPA Partner Survey

Form Approved OMB No. 0990-XXXX

Exp. Date XX/XX/XXXX

National Partnership for Action to End Health Disparities (NPA) Partner Survey

Introduction: Welcome to the survey being conducted by Community Science on behalf of the Office of Minority Health in the U.S. Department of Health and Human Services. This survey is designed to collect information on your involvement with efforts to end health disparities, including the National Partnership for Action to End Health Disparities. Your participation is voluntary. You can decline to participate. You can also stop your participation at any time by choosing not to submit your responses.

Your name and organization will not be attached to specific comments that you share today. Your response may be included with those of other respondents in aggregate form in reports or journal articles. In addition, participants’ names will not be included in any information viewed by officials at the Office of Minority Health or any other HHS agency.

Methods will also be taken to protect study data. Data from the survey and interviews will not identify any person. Data from the surveys and interviews will be stored in a password-protected database. Only authorized Community Science staff working on the evaluation will have access to the database. The briefs and reports produced for the evaluation will not identify specific individuals. All potentially identifying information will be destroyed at the study’s conclusion.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-XXXX . The time required to complete this information collection is estimated to average 25 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Please select which region(s) your organization works in (please select all that apply):

□ Region 1 (CT, MA, ME, NH, RI, VT)

□ Region 2 (NJ, NY, PR, USVI)

□ Region 3 (DC, MD, PA, VA, WV)

□ Region 4 (AL, FL, GA, KY, MS, NC, SC, TN)

□ Region 5 (IL, IN, MI, MN, OH, WI)

□ Region 6 (AR, LA, NM, OK, TX)

□ Region 7 (IA, KS, MO, NE)

□ Region 8 (CO, MT, ND, SD, UT, WY)

□ Region 9 (AZ, CA, GU, HI, NV)

□ Region 10 (AK, ID, OR, WA)

What is the State you work in?

Dropdown of 50 states and 3 territories

1. Please describe the goals of your partnership with the Office of Minority Health (OMH) to implement the National Stakeholder Strategy to Achieve Health Equity (NSS) and support the National Partnership for Action to End Health Disparities (NPA).

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

2. Please indicate the degree to which you agree or disagree with the following statements regarding your partnership with OMH around the NSS and NPA.

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
My organization has obtained additional funds from sources other than OMH to end health disparities as a result of our involvement with the NPA.	1	2	3	4	5
My organization has acquired additional knowledge and skills to end health disparities as a result of our involvement with the NPA.	1	2	3	4	5
My organization has a clear understanding about our role and responsibilities in supporting the NPA.	1	2	3	4	5
My organization actively engages in activities that are effective in helping achieve the NPA’s 5 goals and in implementing the 20 strategies.	1	2	3	4	5
Our partnership with OMH includes collaborating with one another and/or other NPA partners to problem solve shared problems and overcome obstacles to our progress.	1	2	3	4	5
The partnership has a clear strategy and actions for engaging federal agencies to help end health disparities.	1	2	3	4	5
Other ways the partnership with the NPA has impacted my organization’s work to address health disparities. Please describe: Allow text entry __________________________

3. Did your participation in the partnership with OMH around the NSS and NPA help your organization develop or strengthen relationships with any of the following entities or increase your support for them? (please check all that apply and provide a brief description where appropriate about the nature of the relationship or support)

• Federal agencies

(If you checked this, please describe the nature of the relationship or support:

_____________________________________________________________________________)

• Regional organizations or coalitions working to end health disparities

(If you checked this, please describe the nature of the relationship or support:

_____________________________________________________________________________)

• Regional Health Equity Councils (RHECs)

(If you checked this, please describe the nature of the relationship or support:

_____________________________________________________________________________)

• State agencies, organizations, or coalitions working to end health disparities

(If you checked this, please describe the nature of the relationship or support:

_____________________________________________________________________________)

• Tribal leaders or organizations working to end health disparities

(If you checked this, please describe the nature of the relationship or support:

_____________________________________________________________________________)

• Philanthropic organizations working to end health disparities

(If you checked this, please describe the nature of the relationship or support:

_____________________________________________________________________________)

• Businesses working to end health disparities

(If you checked this, please describe the nature of the relationship or support:

_____________________________________________________________________________)

• City or county agencies, organizations, or coalitions working to end health disparities

(If you checked this, please describe the nature of the relationship or support:

_____________________________________________________________________________)

• Rural organizations or coalitions working to end health disparities

(If you checked this, please describe the nature of the relationship or support:

_____________________________________________________________________________)

• Grassroots organizations or coalitions working to end health disparities

(If you checked this, please describe the nature of the relationship or support:

_____________________________________________________________________________)

4. Did your organization integrate information about health disparities into its mission and goals as a result of being involved with the NPA?

• No

• Yes

5. Did your organization develop a new strategy or plan to address health disparities or improve an existing strategy or plan as a result of being involved with the NPA?

• No

• Yes, we developed a new strategy or plan

• Yes, we improved an existing strategy or plan

6. Did your organization integrate information about health disparities into your organizational materials, including the organization’s website, as a result of being involved with the NPA?

• No

• Yes

7. Which of the following social determinants of health are addressed by your partnership with OMH? (please check all that apply)

• Housing

• Education

• Health care system

• Employment/Jobs

• Environment

• Transportation

• Food Security

• Other (please specify: ___________________________________)

1. To what degree has your organization achieved the goals it set out to achieve through your partnership with OMH?

Not at all	A Little	Some	A Great Deal	Completely
1	2	3	4	5

2. How satisfied have you been with the following support provided for the NPA?

	Very Dissatisfied	Dissatisfied	Neither Satisfied nor Dissatisfied	Satisfied	Very Satisfied	Have not used/Don’t Know Enough to Assess
Leadership provided by OMH staff	1	2	3	4	5	6
Assistance with communications and other media-related activities	1	2	3	4	5	6
Assistance with collecting data, using data, and evaluating progress toward your goals for the partnership	1	2	3	4	5	6
Assistance with coordination and facilitation of meetings and other exchanges	1	2	3	4	5	6
Follow-up on requests for assistance

*(if answered “Don’t Know Enough to Assess/Have not Used” to all of the last 4 questions, skip to question 12)

3. What support or assistance has been most helpful?

__________________________________________________________________________________

4. What has been least helpful?

_________________________________________________________________________________

5. What would you recommend to improve support and technical assistance?

_________________________________________________________________________________