Section 1: OrganizationName of person submitting* What FOPO Organization are you representing?* Does your organization have a statement against anti-racism?* Yes No Please enter your organization's anti-racism statementDoes your organization have a written charge to combat systemic racism and to ensure diversity, equity and inclusion within your organization?* Yes No Please enter your organization's written charge to combat systemic racismDoes your organization have a Diversity, Equity and Inclusion Committee (or comparable group)?* Yes No Who is the group's Chair? What is the Chair's email address? What is the group's charge/major initiatives? When was the group created? Section 2: Data CollectionDo you collect membership demographics about race/ethnicity, gender, gender identity, sexual orientation, abilities* Yes No How do you collect membership demographics (i.e. through dues renewal)? How long have you been collecting membership demographic data? Please list the demographic information you collectIs it mandatory for your membership to report demographics, or optional?* Mandatory Optional What percentage of your membership typically reports their demographic information? Can you share your demographic statistics with FOPO?* Yes No Is there a clear goal you’re trying to achieve by collecting these data? Yes No Do you plan to begin collecting demographic information? Yes No If you have a Journal do you collect demographic information from authors?* Yes No No journal Section 3: LeadershipWhat is the make-up of your Board?* American Indian or Alaska Native Asian or Asian American Black or African American Hispanic, Latino, or of Spanish Origin Native Hawaiian or Other Pacific Islander Non-Hispanic White Prefer to self-describe Prefer not to answer How many board members identify as American Indian or Alaska Native?How many board members identify as Asian or Asian American?How many board members identify as Black or African American?How many board members identify as Hispanic, Latino or Spanish Origin?How many board members identify as Non-Hispanic White?How many board members identify as Prefer to self-describe?How many board members identify as Prefer not to answer?Does your organization do anything to promote diversity within your leadership?* Yes No Please describe what your organization does to promote diversity within your leadershipSection 4: ProgramsDo you have any programs specifically for Under-Represented in Medicine (URiM) individuals?* Yes No No, but plan to Please explain your current programs specifically for Under-Represented in Medicine (URiM) individualsPlease explain how your organization plans to establish programs specifically for Under-Represented in Medicine (URiM) individualsDo you make efforts to recruit diverse applicants into your organization/committees/programs?* Yes No No, but plan to Please explain how you make efforts to recruit diverse applicants into your organization/committees/programsPlease explain how you plan to make efforts to recruit diverse applicants into your organization/committees/programsSection 5: Webinars, Publications and Continuing EducationHave you hosted webinars on diversity, equity, inclusion, health disparities, systemic racism, etc.?* Yes No Please enter webinar titles and speakersHas your organization published on diversity, equity, inclusion, health disparities, systemic-racism, etc.?* Yes No Please share title, author(s) and place of publicationHave you, or do you plan to, incorporate diversity, equity, inclusion, health disparities, systemic-racism, etc. at your annual conference (if applicable)?* Yes, this was a focus at our most recent meeting Yes, this will be a focus at our upcoming meeting No, we do not plan to No, we do not sponsor an annual conference How was this addressed during the meeting? (i.e. workshops, meeting theme, abstracts, keynote speaker, etc.) How will this be incorporated? (i.e. workshops, meeting theme, abstracts, keynote speaker, etc.) What activities is your organization doing to address DEI in organizational role modeling (that isn’t already captured above)?*What activities is your organization doing to address DEI in the training environment (that isn’t already captured above)?*What activities is your organization doing to address health care disparities (that isn’t already captured above)?*What activities is your organization doing to develop a UIM pathway/pipeline (that isn’t already captured above)?*What EDI opportunities do you see that we could collaborate on through FOPO (consider: Organizational Role Modeling, Training Environment, Health Care Disparities, Develop UIM pathway/pipeline)?*Click here to upload supplementary documents (if applicable) Drop files here or Select files Max. file size: 128 MB, Max. files: 10. CAPTCHA