CATCH UP 2.0 Quality Feedback Form – Public Health Institute of Oklahoma

Local Community Advisor Feedback Form: Quality Improvement & Community Voice

Your voice is very important to improve systems throughout Oklahoma. To increase equity and address Covid-19 health disparities, the Public Health Institute of Oklahoma and the CATCH-UP 2.0 Project advances family voice to increase quality AND removes barriers for participation, as funding is available. This agreement is entered into between Public Health Institute of Oklahoma and the community advisor listed below for the purposes of collecting quality feedback and providing compensation and/or reimbursements for community advisor/family leadership activities, as funding is available.

Section 1: Contact Information

Join our team of family leaders/community champions!

County *

What county or counties do you live in or work in currently?

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Do you prefer text, phone call, or email? *

Text
Phone Call
Email
Any of the above

Race/ethnicity: We value and welcome ALL diverse members of our community *

Name of Regional Coordinator who provided you this form: *

Feedback on Family Leadership Activities:

Sharing your lived experiences (positive and negative) with Oklahoma systems will help quality improvement efforts and address Covid-19 health related issues. We also want to connect you with additional resources and supports, as interested.

Date of meeting/activity that you attended (month, day and year): *

Name of activity (meeting, conference, training, etc.): *

Did you participate "on the clock" or "off the clock"? *

“on the clock” – State employees do not qualify for stipend or reimbursement
“on the clock” – Paid private employee; Part of job description/contract pays for time
“off the clock” – Paid private employee; duties outside any current contract hours
“off the clock” – Unemployed/volunteer family leader/youth leader

Building an equitable pipeline for supporting and empowering family leaders/community champions. *

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
Did your knowledge, skills, or awareness increase?	Strongly DisagreeDid your knowledge, skills, or awareness increase? Strongly Disagree	DisagreeDid your knowledge, skills, or awareness increase? Disagree	NeutralDid your knowledge, skills, or awareness increase? Neutral	AgreeDid your knowledge, skills, or awareness increase? Agree	Strongly AgreeDid your knowledge, skills, or awareness increase? Strongly Agree
Will you use any of the strategies in your community?	Strongly DisagreeWill you use any of the strategies in your community? Strongly Disagree	DisagreeWill you use any of the strategies in your community? Disagree	NeutralWill you use any of the strategies in your community? Neutral	AgreeWill you use any of the strategies in your community? Agree	Strongly AgreeWill you use any of the strategies in your community? Strongly Agree

Key take-aways from event/meeting: *

What went well? *

What needs improvement? Any barriers or solutions identified? *

Would you be willing to share feedback with other community leaders to improve Oklahoma systems? *

Yes
No
Maybe, if provided mentoring opportunities

Removing Barriers for Participation

We honor your time and expertise! As funding allows, we will remove barriers for participation.

We value your time and want to remove barriers for your participation. What barriers need to be removed? *

Total mileage:

Is this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) *

Not evident	Sort of evident	Neutral	Agree	Integrated well
Not evidentIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Not evident	Sort of evidentIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Sort of evident	NeutralIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Neutral	AgreeIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Agree	Integrated wellIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Integrated well

Is this equity-driven approach helpful to you and your community? (we aim to make it a priority to understand individuals'/families' experiences and break down barriers created by systemic, institutional, and individual racism) *

Not evident	Sort of evident	Neutral	Agree	Integrated well
Not evidentIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Not evident	Sort of evidentIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Sort of evident	NeutralIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Neutral	AgreeIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Agree	Integrated wellIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Integrated well

Is this approach collaborative? (we aim to develop strong partnerships with parents/caregivers and parent-led organizations to support families to build their power, develop their leadership, and advocate for their children and community) *

Not evident	Sort of evident	Neutral	Agree	Integrated well
Not evidentIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Not evident	Sort of evidentIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Sort of evident	NeutralIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Neutral	AgreeIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Agree	Integrated wellIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Integrated well

Is this approach transparent? (we aim to ensure parents/caregivers/individuals have access to information that allows them to fully participate and influence agency and system-level change processes) *

Not evident	Sort of evident	Neutral	Agree	Integrated well
Not evidentIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Not evident	Sort of evidentIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Sort of evident	NeutralIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Neutral	AgreeIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Agree	Integrated wellIs this approach family-centered? (we aim to prioritize and champion engaging parents/caregivers as partners and leaders as a central strategy to achieving positive, equitable outcomes for all children and their families) Integrated well

Thank you for your time and valuable feedback. Do you have other comments/ideas/suggestions?

Internal Use Only* – Was payment provided by Regional Coordinator?

Internal Use Only* – What type of payment was given by Regional Coordinators?

Internal Use Only*- What are the last four digits of the gift card?

Password

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