Antiracism Learning Collaborative Baseline Survey

Each member of the dyad needs to individually complete this survey. Do not work with your project partner on this survey. If your dyad is selected for the Learning Collaborative, you'll have the opportunity to compare your responses to your partner's.

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* 1. Your name and degree(s)

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* 2. Your project partner's name

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* 3. Medical school or residency program listed on your application for this Learing Collaborative.

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* 4. Please describe why you’re interested in participating in this Learning Collaborative (check primary reason):

I have been charged by my department, residency, or hospital/system to lead our antiracism efforts

I feel like this is an important development area for me personally

I want to use this experience to make changes in our department, residency, or hospital/system

I have been an equity advocate for years, and this seems like a natural extension of that work

I was asked by another person at our department, residency, or hospital/system to be their partner

Other (please describe)

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* 5. Please check each of the following to acknowledge your understanding and agreement. I understand that if selected for this Learning Collaborative, both I and my project partner are required to:

Complete the STFM Leading Change Modules

Attend all in-person and virtual meetings

Create and implement a change plan

Complete at least three additional surveys during the course of the project

Submit a plan for change

Track and report on project results

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* 6. Attach a letter of support from your department chair, dean, or other leader indicating how they and your department/program/institution will support you and your change efforts. The letter should note that you will be given time to attend all virtual and in-person meetings of the Learning Collaborative.

PDF, DOC, DOCX file types only.

Choose File

STFM is collecting the following information as baseline for this project. These metrics will be measured over time:

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* 7. At what level are you wanting to impact change?

Department

Medical School

Residency Program

Hospital/Health System

Other (please specify)

For the remaining questions on this survey, the word "institution" refers to the "level" you chose in the previous question: department, medical school, residency program, hospital/health system, other

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* 8. How confident are you in your skills to lead meaningful change within your institution?

Not at all confident

Extremely confident

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 9. Review the Continuum on Becoming an Anti-Racist Multicultural Organization. Based on the descriptions, where would you rate your institution?

An Exclusionary Institution

A "Club" Institution

Strongly disagree

Strongly agree

Clear

i We adjusted the number you entered based on the slider’s scale.