POST SURVEY ONLY COVID-19 Survey Instrument PRA

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

COVID-19 POST LEARNING COMMUNITY QUESTIONS
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In which Region do you work?
o Region 1: Connecticut, Massachusetts, Maine, New Hampshire, Rhode
Island and Vermont
o Region 2: New Jersey, New York, Puerto Rico and Virgin Islands
o Region 3: Delaware, District of Columbia, Maryland, Pennsylvania,
Virginia and West Virginia
o Region 4: Alabama, Florida, Georgia, Kentucky, Mississippi, North
Carolina, South Carolina and Tennessee
o Region 5: Illinois, Indiana, Michigan, Minnesota, Ohio and Wisconsin
o Region 6: Arkansas, Louisiana, New Mexico, Oklahoma, and Texas
o Region 7: Iowa, Kansas, Missouri and Nebraska
o Region 8: Colorado, Montana, North Dakota, South Dakota, Utah, and
Wyoming
o Region 9: Arizona, California, Hawaii, Nevada, U.S. Associated Pacific
Basin: American Samoa, Commonwealth of the Mariana Islands, Guam,
Federated States of Micronesia, Republic of the Marshall Islands, and
Republic of Palau
o Region 10: Alaska, Idaho, Oregon and Washington

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What is your work area?
o Academia
o Community member
o Community organization
o Local/State/Federal government
o Private sector
o Tribal government and services
o Other_________

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 0990-0379. The time required
to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions,
search existing data resources, gather the data needed, to review and complete 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

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What are your work interests?
o Clinical/Primary Care
o Community Health
o Environmental Health
o Epidemiology
o Health Policy and Management
o Health Promotion and Communication
o Social and/or Behavioral Health
o Other_____

•

What populations do you serve? Choose all that apply
o American Indian/Alaska Native
o Asian American
o Black/African American
o Hispanic/Latino
o Native Hawaiian/Pacific Islander
o LGBTQIA+
o Older adults
o People with disabilities
o Other_____

•

Please indicate all learning sessions you attended:
o Learning Session #1 [TITLE, DATE]
o Learning Session #2 [TITLE, DATE]
o Learning Session #3 [TITLE, DATE]
o Learning Session #4 [TITLE, DATE] (if applicable)

•

Overall, the learning community was beneficial to me and the work I do.
o Strongly Agree
o Agree
o Neutral
o Disagree
o Strongly Disagree

•

The learning community provided valuable information as it relates to racial and
ethnic minorities and American Indian and Alaska Native populations
o Strongly Agree
o Agree
o Neutral
o Disagree
o Strongly Disagree

•

I gained new knowledge as a result of being part of this learning community.
o Strongly Agree
o Agree
o Neutral
o Disagree
o Strongly Disagree

•

The learning community provided valuable networking opportunities.
o Strongly Agree
o Agree
o Neutral
o Disagree
o Strongly Disagree

•

As a result of this learning community, I plan to implement a promising practice,
program and/or policy designed to address the impacts of COVID-19 in racial and
ethnic minority and American Indian and Alaska Native populations
o Strongly Agree
o Agree
o Neutral
o Disagree
o Strongly Disagree

•

As a result of this learning community, I implemented a promising practice,
program and/or policy designed to address the impacts of COVID-19 in racial and
ethnic minority and American Indian and Alaska Native populations
o Strongly Agree
o Agree
o Neutral
o Disagree
o Strongly Disagree

•

Please provide any Additional Comments regarding your thoughts and
experience as a member of the COVID-19 Learning Community:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
_________________________________________________________