PLEASE FAX TO 303.744.8724, ATTN SARAH SEVILLA-LOVATO – 303.744.2088 EXT 315
Susan G. Komen Colorado
50 S. Steele St.
Suite 100
Denver, CO 80209
Phone: 303-744-2088|Fax: 303-744-8724|www.komencolorado.org
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To: / From: / Komen ColoradoFax: / Pages: / 3, including cover sheet
Phone: / Date:
Re: / Key Informant Survey / Cc: / Toni Panetta; Sarah Sevilla-Lovato
☐Urgent / ☐For review / ☐Please comment / ☒Please reply / ☐Please recycle
Comments:
Komen Colorado, the local affiliate of Susan G. Komen, completes a community needs assessment every four years to understand the state of the breast cancer burden in the organization’s service area. This information will be vital for developing grant funding and programming priorities for Komen Colorado’s work over the next five years.
Attached is a survey that represents one component of the assessment. As a provider of breast health services in Colorado, your input is critical to understanding the issues and needs of our service area. Thank you for your participation in this survey.
Organization Name:______
Facility Street Address:______
City:______State:______Zip Code+4:______
Public Contact Phone:______
Facility URL/Website:______
Do you have multiple locations:
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Yes
No
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Organization Type: Please check all that apply.
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Cancer Center
City/County Health Department
Community Based Organization
Community Health Center
FQHC
FQHC Look-alike
Free Clinic
Hospice
Hospital: Private
Hospital: Public
Imaging Center
Rural Health Center
Surgical Outpatient
Women’s Health Clinic
Other:______
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Non-profit:
Yes
No
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
If your organization has a separate foundation, please provide name and contact information below:
______
Development Director Name:______
Phone Number:______
Email:______
Breast Health Navigator Name:______
Phone Number:______
Email:______
Is there anyone else that we should contact at your organization to understand how your facility navigates patients/clients who have abnormal breast health symptoms? If no one, please mark N/A.
Name:______
Phone Number:______
Email:______
What counties does your organization serve?______
______
What type of breast health care services does you organization provide? Please check all that apply.
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Mammography (mobile – digital mammography): screening
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Mammography (mobile with tomosynthesis): screening
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Mammography (in-clinic): screening diagnostic
Mammography (in-clinic with tomosynthesis): screening diagnostic
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Clinical Breast Exam (CBE)
Patient Navigation into Diagnostics
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Genetic testing/counseling
Ultrasound
MRI
Biopsy
Patient Navigation Into Treatment
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Radiation
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Chemotherapy
Surgical Consult
Surgery
Reconstruction
Patient Navigation to Support Services
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Support Groups
Side effect management
Individual Counseling/Psychotherapy
Exercise/Nutrition Programs
Complementary Therapies
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Financial Assistance
End of Life Care
Legal Services
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Education on Family History/Breast Cancer
Lifestyle Risk Factors for Breast Cancer (Obesity, Alcohol, Exercise)
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Education on Abnormal Breast Changes
Other:______
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
If you do not provide breast health care, where do you refer clients who need this service?______
______
What accreditations does your organization have? Please check all that apply.
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
American College of Surgeons CoC Accredited
American College of Radiology Breast Imaging Center of Excellence
National Committee of Quality Assurance for Patient Centered Medical Homes
American College of Surgeons NAPBC Accredited
NCI Designated Cancer Center
Other:______
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
What types of payment does your organization accept? Please check all that apply.
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Self-Pay
Medicaid
Medicare
CICP
Veteran's/Military/TriCare
Private Insurance
Women’s Wellness Connection
Other:______
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Does your organization participate in any of the following? Please check all that apply.
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Colorado Accountable Care Collaborative
Comprehensive Primary Care Initiative
FQHC Advanced Primary Care Practice Project
Medicaid Global Payment Initiative
iCare for Rural Health/Critical Access Hospitals
Other:______
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
If your organization provides charity care, at what percentage % of Federal Poverty Level (FPL) do you provide it?
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
100% FPL
138% FPL
200% FPL
250% FPL
300% FPL
Other:______
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Does your Federal Poverty Level population belong to any of the following categories? Please check all that apply.
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Lives in a mountain/resort region
Latina/Hispanic
Lives in a rural region
Foreign-Born
N/A
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Thinking about your Clients/Patients from the past 12 months, what percentage of your clients/patients are foreign-born?______
What percentage of your foreign-born clients/patients, fall into each of the categories below? (Some clients/patients may be included in multiple categories).
Legal Permanent Resident (Green Card Holder):______
Legal Permanent Resident (Green Card Holder) for Less Than 5 Years:______
Temporary Visa Holders:______
Otherwise Undocumented:______
Mixed Document Households (i.e., some members of household are documented and others are not):______
______
Besides English, what other languages do your patients/clients speak?______
______
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit
Health System Inventory Tool was provided by Susan G. Komen Colorado for use in the Module 3 Toolkit