Application for

Learning Community on the Implementation of the National CLAS Standards in Behavioral Health Systems

DEADLINE APRIL 30, 2014
to mailto:

Contact Information

1

Name

Title

Organization

Mailing Address

Cell Phone Number

Office Phone Number

Fax Number

Email address

Anyaccommodations needed for communication via webinar?

1

GRANT Information

Are you receiving a System of Care Grant from SAMHSA?

____ Yes

____ No

What type(s):

___ 6 yr Community

___ 1yr Expansion Planning

___ 4yr Expansion Implementation

Are you receiving a different type of Grant from SAMHSA?

____ If yes, type and name ______

____ No

Are you applying as a member of a two person team from your state?

____ If yes, please provide the name, title, and organization of the other person ______

______

______

____ No

ABOUT THE LEARNING COMMUNITY

This Learning Communityon the Implementation of the National CLAS Standards in Behavioral Health Systemsis designed for you to learn and test strategies for organizational implementation of the HHS Office of Minority Health’s National CLAS Standards in behavioral health systems. As a member of this Learning Community, you will participate in bimonthly discussions where you will learn more about the intent of the Standards, share organizationalexperiences related to the implementation of the Standards,anddiscover and evaluate additionalimplementation strategies. You willdescribe the issues that are unique to your behavioral health setting, and collaborate with others to develop strategies to address your shared challenges. Unlike a routine webinar series,yet similar to the Plan- Do-Study- Act model of many learning collaboratives, this Learning Community will require an investment of your consistent participation during and between session activities.The Learning Community will take place over a 12-month period using webinar technology to convene on a bimonthly basis. Sessions will beheld on thethird Tuesdays of alternating months from 3:00 pm – 4:30 pm Eastern (except for the month of July).The tentative schedule for these meetings is:

  • May 20, 2014
  • July 8, 2014
  • September 16, 2014
  • Nov 18, 2014
  • Jan 20, 2015
  • March 17, 2015
  • May 19, 2015

ABOUT YOU AND YOUR ORGANIZATION

Please provide brief responses to the following questions to help us createa Learning Community with a diverse membership, representing multiple strengths and challenges.

  1. Please provide a brief description of your setting and your role (e.g., Type of organization? Who does it serve? What is the size? What is your role? What are your CLC responsibilities?etc.).{100 words maximum}
  1. Why do you want to participate in the Learning Community on the Implementation of the National CLAS Standardsin Behavioral Health Settings?{50 words maximum}
  1. What would you like to learn from your participation in this Learning Community? {50 words maximum}
  1. Please indicate the current level of National CLAS Standards implementation in your setting:
  1. ____ No activity
  2. ____ Minimal activity (e.g., offers a few sporadic trainings on CLAS).
  3. ____ Moderate activity (e.g., has an established, ongoingtraining program on CLAS)
  4. ____ Maximum activity (e.g., actively implementing most of the Standards, has ongoing

evaluation of CLAS activities and initiatives, etc.)

  1. Provide a brief list of the skills, knowledge, and experience related to cultural and linguistic competency that you could contribute to this Learning Community.{50 words maximum}
  1. Please share any other information that we should know about you.{100 words maximum}
  1. Can you commit to ongoing participation in this Learning Community over the next 12 months, which includes, but is not limited to, testing new ideas in your setting, engaging in off-line study and preparation, and leading some Learning Community discussions?

____ Yes

____ No

  1. What questions do you have about this Learning Community?

DEMOGRAPHIC PROFILE (VOLUNTARY)

We would like to have a profile of the demographic characteristics of applicants for the Learning Community. We would appreciate your completion of the following information on a VOLUNTARY BASIS. We are using the HHS Standards for Collection of Race Ethnicity, Sex and Disability template as an opportunity to become more familiar with this tool.

Ethnicity

Are you Hispanic, Latino/a, or Spanish origin (One ormore categories may be selected)

  1. No, not ofHispanic, Latino/a, or Spanish origin
  2. Yes, Mexican, Mexican American,Chicano/a
  3. Yes, Puerto Rican
  4. Yes, Cuban
  5. Yes, Another Hispanic, Latino/a orSpanishorigin

Race

Whatis your race?(One ormore categoriesmay be selected)

1

  1. White
  2. Black or African American
  3. American Indian orAlaska

Native

  1. Asian Indian
  2. Chinese
  3. Filipino
  4. Japanese
  5. Korean
  6. Vietnamese
  7. Other Asian
  8. NativeHawaiian
  9. Guamanianor Chamorro
  10. Samoan
  11. ____Other Pacific Islander

1

Sex

What is your sex?

_____ Male

_____Female

Primary Language

How well do you speak English? (5 years old or older)

  1. Verywell
  2. Well
  3. Not well
  4. Not at all

Do you speak a language other than English at home? (5 years old or older)

a. ____ Yes

b. ____ No

For persons speaking a language other than English (answering yes to the question above):

What is this language? (5 years old or older)

a. ____Spanish

b. ____Other Language (Identify)______

Data Standard for Disability Status

1. Are you deaf or do you have serious difficulty hearing?

a. ____ Yes

b. ____No

2. Are you blind or do you have serious difficulty seeing, even when wearing glasses?

a. ____ Yes

b. ____No

3. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? (5 years old or older)

a. ____Yes

b. ____No

4. Do you have serious difficulty walking or climbing stairs? (5 years old or older)

a. ____Yes

b. ____No

5. Do you have difficulty dressing or bathing? (5 years old or older)

a. ____Yes

b. ____ No

6. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? (15 years old or older)

a. ____Yes

b. ____ No

FOR MORE INFORMATION

For additional information or questions, please contact:

Vivian H. Jackson at or

Crystal L. Barksdale at

THANK YOU FOR YOUR COMMITMENT TO ENDING DISPARITIES AND PROMOTING

Culturally and Linguistically Appropriate Services!

Applications are due by Friday April 25th at 5pm (EDT) to

and

you will be notified by May 9th

1