Developing a Self-Assessment Toolfor Culturally - Office of Minority ...

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Organization Code:Questionnaire:Appendix F______________________________________PILOT TEST RESPONSE FORMInstructions:1. Please use this form to record your responses to the Pilot Test Questionnaire Package.If different staff members share the effort of completing the questionnaire, pleaseallow each individual to complete this form for the appropriate section(s). Forexample, if one staff member completes sections A through C of the questionnaireand another staff member completes section D, each staff member should record theirresponses in the table on page 2 of this form only for the section(s) that correspond tothe section(s) they completed in the questionnaire.2. On page 2, rate the utility of each component (cover letter; questionnaire cover sheet;and questionnaire sections A-D) based on the categories provided and the followingrating scale: (1 = very appropriate); (2 = appropriate); (3 = somewhat appropriate);and (4 = not appropriate). In using the rating scale, consider the level ofappropriateness for presenting each component to someone in a similar staff positionto yours. Also, if you rate a particular component category as “3" (somewhatappropriate) or “4" (not appropriate), please let us know why, or give suggestions forchange, by commenting in the box provided on page 3 of this form.Please evaluate each questionnaire section as a whole, but feel free to provide writtencomments in the box on page 3 if there are particular items of concern within asection. If you provide written comments on a particular question or item, pleaseindicate the questionnaire section and question number you are referring to.3. In addition, your general comments and suggestions about the design or topicalcontent of the questionnaire, or specific questions within, are greatly appreciated.4. Finally, please return this Pilot Test Respondent Evaluation Form with yourcompleted questionnaire.Thank you.COSMOS Corporation, December 2003 F-1
RESPONDENT EVALUATIONOF THE QUESTIONNAIRE PACKAGERATING SCALE (please circle)COMPONENTVery Appropriate Appropriate Somewhat Appropriate Not AppropriateCover Letter1. Layout and Design 1 2 3 42. Clarity of Information 1 2 3 43. Motivational Effect to Participate 1 2 3 4Questionnaire Cover Sheet1. Layout and Design 1 2 3 42. Clarity of Information 1 2 3 43. Clarity of Return Instructions 1 2 3 44. Options for Returning CompletedQuestionnaire1 2 3 4Questionnaire, Section A1. Layout and Design 1 2 3 42. Clarity of Instructions 1 2 3 43. Question Wording 1 2 3 44. Response Categories 1 2 3 45. Ability to Recall Information 1 2 3 4Questionnaire, Section B1. Layout and Design 1 2 3 42. Clarity of Instructions 1 2 3 43. Question Wording 1 2 3 44. Response Categories 1 2 3 45. Ability to Recall Information 1 2 3 4Questionnaire, Section C1. Layout and Design 1 2 3 42. Clarity of Instructions 1 2 3 43. Question Wording 1 2 3 44. Response Categories 1 2 3 45. Ability to Recall Information 1 2 3 4Questionnaire, Section D1. Layout and Design 1 2 3 42. Clarity of Instructions 1 2 3 43. Question Wording 1 2 3 44. Response Categories 1 2 3 45. Ability to Recall Information 1 2 3 4**Please estimate the amount of time it took you to complete the questionnaire: _______________Would it be useful to have an additional option for completing and submitting the questionnaire onan Internet web site? Yes ____ No ____COSMOS Corporation, December 2003 F-2
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Developing a Self-Assessment Toolfo
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ContentsChaptersPage1. Introduction
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Chapter 1Introduction
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While many LPHAs currently provide
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LPHAs include: adult and child immu
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Professions Education Partnership A
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Chapter 2Methodology for Developing
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Public Health Practice Program Offi
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assess their own beliefs and have k
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communicate with, and clearly under
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2.1.6 Identifying Key Components of
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Given these persistent disparities
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(Exhibit 2-2, Continued)DOMAIN / KE
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limited to the actual clinical enco
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Chapter 3Project Results and Recomm
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local board of health. PEP and PAG
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numerous promising CLAS practices a
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References
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Becker, M.H., and L.A. Maiman, “S
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Frye, B., “Health Care Decision M
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Marin, G., “Defining Culturally A
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Perkins, Jane, “Overcoming Langua
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U.S. Bureau of the Census, “Censu
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Appendix AMembership Lists of the P
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Appendix A-1Developing a Self-Asses
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Appendix A-2Developing a Self-Asses
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Appendix B-1Overview of Eight CLAS
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Domain 3: Culturally Inclusive Heal
Page 57 and 58: understanding of diversity issues i
Page 59 and 60: Appendix B-2Conceptual Framework fo
Page 61 and 62: Appendix CLPHA Director or Designee
Page 63 and 64: Pre-Interview Script for LPHA Direc
Page 65 and 66: 3b. Which of the following are refl
Page 67 and 68: 6. Does your agency have a formal p
Page 69 and 70: 10. Which of the following describe
Page 71 and 72: Post-Interview Script for LPHA Dire
Page 73 and 74: Appendix DStaffing Questionnaire
Page 75 and 76: A. QUALITY MONITORING AND IMPROVEME
Page 77 and 78: B. MANAGEMENT INFORMATION SYSTEMS (
Page 79 and 80: 7. Please indicate, if you know, th
Page 81 and 82: 1c. Please indicate for which categ
Page 83 and 84: 6. Please indicate for which catego
Page 85 and 86: 10. Which of the following topical
Page 87 and 88: 17. Which of the following benefits
Page 89 and 90: 4. Which of the following strategie
Page 91 and 92: Appendix EClient Services Questionn
Page 93 and 94: A. QUALITY MONITORING AND IMPROVEME
Page 95 and 96: 6b.Which of the following community
Page 97 and 98: 3. Please report or estimate what p
Page 99 and 100: 3. Which of the following practices
Page 101 and 102: Oral Interpretation Services10. Whi
Page 103 and 104: 16. At which of the following key e
Page 105 and 106: 3. Which of the following kinds of
Page 107: Appendix FPilot Test Response Form
Page 111 and 112: Appendix GCLAS in MCOs Study Data C
Page 113 and 114: position, as titles will likely var
Page 115 and 116: complex and uncertain at the time t
Page 117 and 118: 1. Incorporate a confirmation pre-c
Page 119 and 120: Exhibit 2DATA COLLECTION PROCESSSen
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