Health & Health Care Organization Screener
FORM APPROVED
OMB No: 0990-XXXX
Expires: MM/DD/YYYY
The U.S. Department of Health and Human Services’ Office of Minority Health (HHS OMH) is sponsoring an inaugural evaluation to systematically examine and document the awareness, knowledge acquisition, adoption, and implementation of The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (the National CLAS Standards) among health and health care organizations (H/HCOs) in the United States. The results of this unprecedented study will inform the development of a practical tool to guide H/HCOs such as your organization in their efforts to provide quality care to the culturally and linguistically diverse populations they serve.
Please take a moment to answer the following brief questions.
What is your name and title?
What is the name and location of your organization?
Name: _______________________________________
Location (city, state): ___________________________
Does your organization implement culturally and linguistically appropriate services (CLAS)?
No
Yes
I don’t know
Does your organization implement the HHS Office of Minority Health’s National CLAS Standards?
No
Yes
I don’t know
Is your organization interested in participating in an evaluation project about CLAS and the National CLAS Standards?
No
Yes
Please share the contact information of the individual(s) who can best discuss your organization’s participation in this evaluation project.
Name: _______________________________________
Email Address: ________________________________
Phone Number: ________________________________
Name: _______________________________________
Email Address: ________________________________
Phone Number: _______________________________
Name: _______________________________________
Email Address: ________________________________
Phone Number: ________________________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Barksdale, Crystal |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |