OFFICE OF THE DIRECTOR
Office of Equity and Inclusion
Developing Equity Leadership through Training and Action
2016 Central/Eastern Oregon Sub-cohort Application
Please complete the following and submit via e-mail or fax by February 29, 2016. This document can be provided
upon request in an alternate format for individuals with disabilities or in a language other than English for people
with limited English skills. To request this publication in another format or language, contact Anastasia Sofranac at
971-673-1333, anastasia.sofranac@state.or.us.
Name:
Last
First
Title:
Middle
Organization:
Street address:
City:
State:
Phone number:
Check one:
Zip:
Home
Cell
Work
Email:
Demographic information
This information is optional. Under federal and state law, this information cannot be used to discriminate
against you. We will use this information to support equitable representation in the DELTA cohort.
Race and ethnicity (check all that apply):
American Indian/Alaska Native
American Indian
Alaska Native
Canadian Inuit, Metis or First Nation
Indigenous Mexican, Central American
or South American
Pacific Islander
Native Hawaiian
Guamanian or Chamorro
Samoan
Micronesian
Tongan
Other Pacific Islander
Other American Indian
Hispanic, Latino
Hispanic or Latino Mexican
Hispanic or Latino Central American
Hispanic or Latino South American
Other Hispanic or Latino:
African/African American/Black
African American
African
Caribbean
Other Black
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Asian
White
Chinese
Vietnamese
Korean
Hmong
Laotian
Filipino/Filipina
Japanese
South Asian
Asian Indian
Other Asian
Disability:
Yes
Western European
Eastern European
Slavic
Middle Eastern
Northern African
Other White
Other categories
Unknown
Decline to answer
Other (please list):
No
Which county do you work and/or reside in?
What type of organization are you currently employed with?
Coordinated Care Organization (CCO)/hospital
Local or State Health Department
Community-based or nonprofit organization
Policy sector
Clinical practitioner
Other (please indicate):
Questions
1. Please tell us why you are interested in participating in the DELTA program. Describe any past experience
participating in equity-related trainings, workshops, etc. (200 words or less).
2. Please describe one barrier to health equity that can be addressed at a systemic level in your organization
(i.e. collecting race/ethnicity data, strategic planning to address disparities, hiring/retention, etc.)
(200 words or less).
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3. In what capacity can you influence this change or share the information obtained in DELTA with your
organization (200 words or less)?
4. Briefly describe a current or potential health equity project or plan in your organization that you would be able to
work on while in the DELTA program and discuss with others during the training (200 words or less)?
5. Are you aware of other employees/co-workers at your organization who have also participated in the
DELTA program?
6. Please submit a current résumé, no longer than 2 pages.
Training sessions for this pilot cohort will be held over the course of four months (April 2016 –July 2016). The
sessions will be held for two consecutive days per month for a total of eight days. Locations will depend on
composition of cohort members and contribution of space. We ask that participants commit to missing no
more than one training session. Please indicate which set(s) of consecutive days would work best for you:
Thursday and Friday
Friday and Saturday
Monday and Tuesday
Applicant’s signature
Date
Supervisor signature
Date
Name of potential or current mentor (optional)
Date
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Please email or fax application to:
Anastasia Sofranac
DELTA Coordinator
Office: 971-673-1333
Oregon Health Authority
Office of Equity and Inclusion
421 SW Oak Street, Suite 750
Portland, OR 97204
Anastasia.Sofranac@state.or.us
971-673-1128 (fax)
The DELTA Program described is supported by Funding Opportunity Number CMS-1G1-12-001 from the U.S Department of
Health and Human Services, Centers for Medicare & Medicaid Services and the content provided is solely the responsibility of
the authors and do not necessarily represent the official views of HHS or any of its agencies.
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