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<h1>Interim Feedback Forms</h1>
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<h2>Evaluation of a Learning Collaborative's Process and Effectiveness to Reduce Health Care Disparities Among Minority Populations</h2> <div id="basic-modal"><!-- start: Basic Modal -->
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<strong>Note:</strong> Feedback form draws heavily on Van de Ven and Ferry (1980), with permission from the authors. <table border="1" cellpadding="8" cellspacing="0" summary="layout" width="100%"><tbody><tr valign="top"><td><p align="center"><strong>Interim Feedback on the Collaborative's Value and Structure from Organizations Participating in the National Health Plan Collaborative to Reduce Disparities</strong></p><p align="center">Sponsored by: Agency for Health Care Research and Quality (AHRQ)<br />Conducted by: Mathematica Policy Research, Inc.</p><table align="center" border="1" cellpadding="8" cellspacing="0" summary="layout" width="60%"><tbody><tr valign="top"><td align="center"><p><strong>Organization Label Here</strong></p><p>(Name, Address, Telephone)</p></td></tr></tbody></table><br /><br /><table align="center" border="1" cellpadding="8" cellspacing="0" summary="layout" width="80%"><tbody><tr valign="top"><td><p><strong>About This Request</strong></p><p>The National Health Plan Collaborative involves many organizations working together to reduce disparities. To understand how the collaborative functions, we are requesting feedback on your organization's <strong>general perceptions of the collaborative to date</strong> and the <strong>relationships between collaborative participants</strong>. There are no right or wrong answers. <strong>Individual responses to this request will be kept completely confidential</strong> and will only be reviewed by researchers at Mathematica Policy Research, Inc. (MPR). <strong>Findings will be reported in de-identified form.</strong> If you have any questions about this request, please call Marsha Gold or Erin Taylor at 202-484-9220. Please be sure to answer every question and mark your answers clearly. <strong>Please return</strong> your completed questionnaire in the postage-paid envelope provided by <strong>Friday, December 16, 2005.</strong></p></td></tr></tbody></table><p>Completed by: _______________________________ Title: ________________________________<br /><br />Organization: _____________________________________________________________________<br /><br />Address: ________________________________________________________________________<br /><br />Telephone: (|  |  |  |)-|  |  |  |-|  |  |  |  |  | (Area - Code Number)<br /><br />Date of Completion: |  |  | / |  |  | /| 2| 0| 0| 5| (Month/Day/Year)</p><p>Prepared by Mathematica Policy Research, Inc.</p></td></tr></tbody></table><table border="1" cellpadding="8" cellspacing="0" summary="layout" width="100%"><tbody><tr valign="top"><td>When answering questions 1 through 9, please think about the last 6 months of the collaborative with regard to disparities. <table border="1" cellpadding="4" cellspacing="0" style=" width: 100%;"><tbody><tr><th rowspan="2" scope="col" width="60%">Questions</th><th colspan="5" scope="col" width="40%">Mark (X) one box for each row</th></tr><tr valign="top"><th scope="col">Not at All<br />Important</th><th scope="col">A Little<br />Important</th><th scope="col">Somewhat<br />Important</th><th scope="col">Very<br />Important</th><th scope="col">Crucial</th></tr><tr><td scope="row">1. Overall, how important was the collaborative in attaining the goals of your organization?</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td> </td><td> </td></tr></tbody></table><br /><table border="1" cellpadding="4" cellspacing="0" style=" width: 100%;"><tbody><tr><th rowspan="2" scope="col" width="60%">Questions</th><th colspan="5" scope="col" width="40%">Mark (X) one box for each row</th></tr><tr><th scope="col">No Extent</th><th scope="col">A Little<br />Extent</th><th scope="col">Some<br />Extent</th><th scope="col">Considerable<br />Extent</th><th scope="col">A Great<br />Extent</th></tr><tr><td scope="row">2. To what extent has the collaborative carried out its responsibilities and commitments?</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row" width="60%">3. To what extent has your organization carried out its responsibilities and commitments to the collaborative?</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row" width="60%">4. To what extent do you feel the relationship between your organization and the collaborative is productive?</td><td align="center">___<sub>1</sub></td><td> </td><td> </td><td> </td><td> </td></tr><tr><td scope="row" width="60%">5. To what extent is the time and effort spent in developing and maintaining the relationship with the collaborative worthwhile?</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row" width="60%">6. Overall, to what extent are you satisfied with the relationship between your organization and the collaborative?</td><td> </td><td> </td><td> </td><td> </td><td> </td></tr><tr><td scope="row" width="60%">7. To what extent has your organization changed or influenced the activities of the collaborative?</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row" width="60%">8. To what extent has the collaborative changed or influenced the activities of your organization?</td><td> </td><td> </td><td> </td><td> </td><td> </td></tr><tr><td scope="row" width="60%">9. Are the payoffs of the collaborative for your organization reasonable relative to your contribution?</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr></tbody></table><p>In questions 10 through 17, we are interested in your organization's experience with other organizations in the collaborative. <strong>For each question, please leave blank the rating of your own organization.</strong></p><p>10. In general, prior to the start of your organization's participation in the collaborative...</p><table border="1" cellpadding="4" cellspacing="0" style=" width: 100%;"><tbody><tr><th rowspan="2" scope="col" width="30%">Organization</th><th colspan="3" scope="col">Were you and your team personally acquainted with the key people from the collaborative organizations listed below?</th><th colspan="2" scope="col">IF YES: To what extent did your organization have an effective working relationship with each of these organizations prior to the start of the collaborative?</th></tr><tr><th scope="col">Yes</th><th scope="col">No</th><th scope="col">To No or<br />Little Extent</th><th scope="col">To Some<br />Extent</th><th scope="col">Considerable<br />Extent</th></tr><tr><td scope="row">Aetna</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>0</sub></td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td></tr><tr><td scope="row">CIGNA</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>0</sub></td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td></tr><tr><td scope="row">Harvard Pilgrim</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>0</sub></td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td></tr><tr><td scope="row">HealthPartners</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>0</sub></td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td></tr><tr><td scope="row">Highmark</td><td> </td><td> </td><td> </td><td> </td><td> </td></tr><tr><td scope="row">Kaiser Permanente</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>0</sub></td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td></tr><tr><td scope="row">UnitedHealth Group</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>0</sub></td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td></tr><tr><td scope="row">CHCS</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>0</sub></td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td></tr><tr><td scope="row">IHI</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>0</sub></td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td></tr><tr><td scope="row">AHRQ</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>0</sub></td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td></tr></tbody></table>11. During the past six months—<strong>outside of formal collaborative meetings</strong>—how frequently have people from your organization who are involved in the collaborative communicated or been in contact with people in the organizations listed below? <table border="1" cellpadding="4" cellspacing="0" style=" width: 100%;"><tbody><tr><th rowspan="2" scope="col" width="30%">Organization</th><th colspan="5" scope="col" width="70%">Mark (X) one box for each row</th></tr><tr><th scope="col">Not at All</th><th scope="col">1-2 Times</th><th scope="col">Monthly</th><th scope="col">Weekly</th><th scope="col">Daily</th></tr><tr><td scope="row">Aetna</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">CIGNA</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">Harvard Pilgrim</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">HealthPartners</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">Highmark</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td> </td><td> </td><td> </td></tr><tr><td scope="row">Kaiser Permanente</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">UnitedHealth Group</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">CHCS</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">IHI</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">AHRQ</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr></tbody></table>12. Overall, <em>how important</em> was each organization's work through the collaborative in attaining the <em>goals of your organization</em> with respect to disparities? <table border="1" cellpadding="4" cellspacing="0" style=" width: 100%;"><tbody><tr><th rowspan="2" scope="col" width="30%">Organization</th><th colspan="5" scope="col" width="70%">Mark (X) one box for each row</th></tr><tr valign="top"><th scope="col">Not at All<br />Important</th><th scope="col">Somewhat<br />Important</th><th scope="col">Moderately<br />Important</th><th scope="col">Very<br />Important</th><th scope="col">Crucial</th></tr><tr><td scope="row">Aetna</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">CIGNA</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">Harvard Pilgrim</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">HealthPartners</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">Highmark</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td> </td><td> </td><td> </td></tr><tr><td scope="row">Kaiser Permanente</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">UnitedHealth Group</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">CHCS</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">IHI</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">AHRQ</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr></tbody></table>13. To what extent has each <em>organization</em> carried out its responsibilities and commitments involving disparities in regard to the collaborative during the past six months? <table border="1" cellpadding="4" cellspacing="0" style=" width: 100%;"><tbody><tr><th rowspan="2" scope="col" width="30%">Organization</th><th colspan="4" scope="col" width="70%">Mark (X) one box for each row</th></tr><tr valign="top"><th scope="col">To No Little Extent</th><th scope="col">To a Little Extent</th><th scope="col">To Some<br />Extent</th><th scope="col">Considerable<br />Extent</th></tr><tr><td scope="row">Aetna</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">CIGNA</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">Harvard Pilgrim</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">HealthPartners</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">Highmark</td><td align="center">___<sub>1</sub></td><td> </td><td> </td><td> </td></tr><tr><td scope="row">Kaiser Permanente</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">UnitedHealth Group</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">CHCS</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">IHI</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">AHRQ</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr></tbody></table>14. To what extent do you feel the <em>relationship</em> between your organization and each of the other organizations with respect to disparities is <em>productive</em>? <table border="1" cellpadding="4" cellspacing="0" style=" width: 100%;"><tbody><tr><th rowspan="2" scope="col" width="30%">Organization</th><th colspan="4" scope="col" width="70%">Mark (X) one box for each row</th></tr><tr valign="top"><th scope="col">To No Little Extent</th><th scope="col">To a Little Extent</th><th scope="col">To Some<br />Extent</th><th scope="col">Considerable<br />Extent</th></tr><tr><td scope="row">Aetna</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">CIGNA</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">Harvard Pilgrim</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">HealthPartners</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">Highmark</td><td align="center">___<sub>1</sub></td><td> </td><td> </td><td> </td></tr><tr><td scope="row">Kaiser Permanente</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">UnitedHealth Group</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">CHCS</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">IHI</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">AHRQ</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr></tbody></table>15. During the past six months, to what extent has <em>your organization changed or influenced</em> the activities of each of these <em>other organizations</em> with respect to disparities? <table border="1" cellpadding="4" cellspacing="0" style=" width: 100%;"><tbody><tr><th rowspan="2" scope="col" width="30%">Organization</th><th colspan="5" scope="col" width="70%">Mark (X) one box for each row</th></tr><tr valign="top"><th scope="col">To No Little Extent</th><th scope="col">To a Little Extent</th><th scope="col">To Some<br />Extent</th><th scope="col">Considerable<br />Extent</th><th scope="col">Cannot Assess</th></tr><tr><td scope="row">Aetna</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">CIGNA</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">Harvard Pilgrim</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">HealthPartners</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">Highmark</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td> </td><td> </td><td> </td></tr><tr><td scope="row">Kaiser Permanente</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">UnitedHealth Group</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">CHCS</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">IHI</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr><tr><td scope="row">AHRQ</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td><td align="center">___<sub>5</sub></td></tr></tbody></table>16. During the past six months, to what extent has each of these <em>other organizations changed or influenced</em> the activities of <em>your organization</em> with respect to disparities? <table border="1" cellpadding="4" cellspacing="0" style=" width: 100%;"><tbody><tr><th rowspan="2" scope="col" width="30%">Organization</th><th colspan="4" scope="col" width="70%">Mark (X) one box for each row</th></tr><tr valign="top"><th scope="col">To No Little Extent</th><th scope="col">To a Little Extent</th><th scope="col">To Some<br />Extent</th><th scope="col">Considerable<br />Extent</th></tr><tr><td scope="row">Aetna</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">CIGNA</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">Harvard Pilgrim</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">HealthPartners</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">Highmark</td><td align="center">___<sub>1</sub></td><td> </td><td> </td><td> </td></tr><tr><td scope="row">Kaiser Permanente</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">UnitedHealth Group</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">CHCS</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">IHI</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr><tr><td scope="row">AHRQ</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td><td align="center">___<sub>4</sub></td></tr></tbody></table>17. Which organizations provide good ideas for dealing with disparities at meetings of the collaborative? <table border="1" cellpadding="2" cellspacing="0" width="98%"><tbody><tr><th rowspan="2" scope="col" width="30%">Organization</th><th colspan="3" scope="col" width="70%">Mark (X) one box for each row</th></tr><tr valign="top"><th scope="col">No Good Ideas</th><th scope="col">Some Good Ideas</th><th scope="col">Many Good Ideas</th></tr><tr><td scope="row">Aetna</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td></tr><tr><td scope="row">CIGNA</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td></tr><tr><td scope="row">Harvard Pilgrim</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td></tr><tr><td scope="row">HealthPartners</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td></tr><tr><td scope="row">Highmark</td><td align="center">___<sub>1</sub></td><td> </td><td> </td></tr><tr><td scope="row">Kaiser Permanente</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td></tr><tr><td scope="row">UnitedHealth Group</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td></tr><tr><td scope="row">CHCS</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td></tr><tr><td scope="row">IHI</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td></tr><tr><td scope="row">AHRQ</td><td align="center">___<sub>1</sub></td><td align="center">___<sub>2</sub></td><td align="center">___<sub>3</sub></td></tr></tbody></table>18. Please use the space below to indicate anything else you want to add relative to the questions above. <table border="1" cellspacing="0" height="240" summary="layout" width="98%"><tbody><tr><td> </td></tr></tbody></table><br /><br /><table align="center" border="1" cellpadding="8" cellspacing="0" summary="layout" width="80%"><tbody><tr valign="top"><td><p>Thank you for completing this request for feedback. Please return your completed questionnaire in the self-addressed, stamped envelope by <strong>Friday, December 16, 2005.</strong> If you do not have the return envelope, please mail to:</p><p align="center">Mathematica Policy Research, Inc.<br />600 Maryland Avenue, S.W., Suite 550<br />Washington, DC 20024-2512<br />or Fax to 202-863-1763<br /><br /><strong>Attn:</strong> Erin Taylor</p></td></tr></tbody></table>Prepared by Mathematica Policy Research, Inc.</td></tr></tbody></table><p class="size2"><a href="/research/findings/final-reports/learning/apc.html#Form">Return to Document</a></p> </div><!-- end: Basic Modal -->
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<div class="current-as-of">Page last reviewed December 2007</div>
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<span>Internet Citation: Interim Feedback Forms: Evaluation of a Learning Collaborative's Process and Effectiveness to Reduce Health Care Disparities Among Minority Populations.
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December 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/research/findings/final-reports/learning/form.html</span>
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