Attachment_8-0990-PatientCentered

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

Attachment 8

Steering Committee Survey

Patient Centered Care Collaboration Initiative to Improve Minority Health

U.S. Department of Health and Human Services’ Office of Minority Health

Steering Committee Survey

Dear Steering Committee Member:

Thank you for agreeing to answer a few questions about the Patient Centered Care Collaboration Initiative. The information you give us will help us to understand your involvement and how the initiative has worked.

Thank you for completing this survey.

Today’s Date

Name

Organization

Organization Address

Number	Street	City	State	Zip Code

Work Telephone

Instructions

Please read each item carefully and provide a response to each one in the space provided.

Please return your completed survey to:

Name

Address

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- . The time required to complete this information collection is estimated to average 1 hour 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 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

1. In what ways did the Patient Centered Care Collaborative (PCCC) project assist community-based organizations to learn more about and implement comparative effective research (CER) findings (e.g., diabetes, hypertension, and obesity education) in their communities?

2. What was the most important role for the steering committee on this project?

3. Were the appropriate steering committee members and stakeholders selected to participate in the PCCC project? Were these the right people to make decisions for this community?

4. Was the project vision understood and shared by all hub members including workgroup members and other involved stakeholders? What role did this play in project discussions and decisions?

5. Did the environmental scan yield useful comparative effectiveness research for this project to consider implementing?

6. How important was it for you to collaborate on this project? Select a response and then explain.

_____ 5=Very important

_____ 4= Moderately important

_____ 3= Important

_____ 2= A little important

_____ 1= Not important

7. How satisfied were you with your level of involvement in the PCCC project? Was it easy to be involved or did you have challenges with your involvement (e.g., meetings were routinely set in my calendar which made it easy to attend; it was difficult to attend meetings due to my work responsibilities)? Select a response and then explain.

_____ 5= Very satisfied

_____ 4= Moderately satisfied

_____ 3= Satisfied

_____ 2= A little satisfied

_____ 1= Not satisfied

8. In what ways did the community-based participatory research approach impact decisions at the project level and was it conducive for accomplishing project goals? Please explain.

9. What benefits did you anticipate from your participation in this project (develop new partnerships for collaborations, opportunities to disseminate information on CER findings)? What benefits did you receive as a result of your participation?

10. In what ways did you facilitate dissemination and promote adoption of these CER findings in your own network?

Office of Minority Health Patient Centered Care Collaboration Initiative		Page 0 of 8