ࡱ> u !tbjbj]] 77f7fN  8tVDg&RJ(rrrZ6 pofqfqfqfqfqfqf$ji lVfi  frr4fp$p$p$ |rrofp$ ofp$p$EHrs"!^F"[fg0DgFvn!~vnDHHvnI p$ ff"r Dg vn  X \: DEPARTMENT OF HEALTH SERVICES Division of Public Health F-01215 (05/2014)STATE OF WISCONSIN Page  PAGE 1 of  NUMPAGES 2national clas standards pledge Culturally and Linguistically Appropriate Services in Health and Health CareThe National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (the National CLAS Standards) are intended to advance health equity, improve quality and help eliminate health care disparities by establishing a blueprint for health and health care organizations to provide effective, equitable, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs. Purpose By pledging to adopt, promote and implement the National CLAS Standards, you will join a large network of non-profit organizations, advocacy groups, foundations, faith-based organizations, professional societies, government agencies, corporations, businesses, industry groups, colleges and universities, and individuals committed to eliminating health disparities and achieving health equity in Wisconsin. Those who pledge to adopt, promote and implement the Standards may be identified on the  HYPERLINK "http://www.dhs.wisconsin.gov/health/minorityhealth/clas/clasindex.htm" Minority Health Program CLAS website, along with the specific  HYPERLINK \l "Standards" Standards they select. Your pledge will allow us to send you information on CLAS-related trainings and other exciting information related to health equity in Wisconsin. Please use the Minority Health Program mailbox at  HYPERLINK "mailto:DHSWIMinorityHealthProgram@dhs.wisconsin.gov" mailto:DHSWIMinorityHealthProgram@dhs.wisconsin.gov to convey needs, contribute ideas and report progress. INSTRUCTIONS To pledge as a Wisconsin CLAS Standards partner: Save the following form as a Word document, fill it out and email it as an attachment to:  HYPERLINK "mailto:DHSWIMinorityHealthProgram@dhs.wisconsin.gov " DHSWIMinorityHealthProgram@dhs.wisconsin.gov OR Print out this form, fill it out and fax it to Minority Health Program at 608-267-2832. You may also access this form online at  HYPERLINK "http://www.dhs.wisconsin.gov/health/minorityhealth/clas/clasindex.htm" http://www.dhs.wisconsin.gov/health/minorityhealth/clas/clasindex.htm. When you pledge, you agree to: Adopt, promote and implement the National CLAS Standards; Raise awareness around heath disparities and  HYPERLINK "http://minorityhealth.hhs.gov/npa/templates/browse.aspx?lvl=1&lvlid=39" promote health equity; and Help develop, plan, and/or implement efforts to advance health equity, improve quality, and help eliminate health care disparities. I am adopting, promoting and implementing the National CLAS Standards (check one):  FORMCHECKBOX  as an individual  FORMCHECKBOX  as a program or service within my agency/organization  FORMCHECKBOX  for my agency/organization as a wholeName of Agency / Organization FORMTEXT      Standard Abbreviation or Acronym of Agency / Organization FORMTEXT      Scope of Agency / Organization s Work (check one)  FORMCHECKBOX  Statewide  FORMCHECKBOX  Regional  FORMCHECKBOX  Local  FORMCHECKBOX  TribalName of Program (if endorsing as a program/service within your organization)  FORMCHECKBOX  N/A FORMTEXT      I will provide a link on my agency/organization s website to the  HYPERLINK "http://www.dhs.wisconsin.gov/health/minorityhealth/clas/clasindex.htm" Minority Health Program CLAS website (located at:  HYPERLINK "http://www.dhs.wisconsin.gov/health/minorityhealth/clas/clasindex.htm" http://www.dhs.wisconsin.gov/health/minorityhealth/clas/clasindex.htm).  FORMCHECKBOX  Yes  FORMCHECKBOX  NoContact NameCredentials (optional) FORMTEXT       FORMTEXT      Position / Title FORMTEXT      Street AddressCity / TownStateZip Code FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT      Telephone NumberFax Number FORMTEXT       FORMTEXT      Email Address FORMTEXT      Website URL FORMTEXT      Select one or more of the National CLAS Standards that best align(s) with your agency or organizational strategic plan. Principal Standard 1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs.Category 1 Governance, Leadership and Workforce  FORMCHECKBOX  Select ALL in Category 1 FORMCHECKBOX Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices and allocated resources. FORMCHECKBOX Recruit, promote and support a culturally and linguistically diverse governance, leadership and workforce that are responsive to the population in the service area. FORMCHECKBOX Educate and train governance, leadership and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.Category 2 Communication and Language Assistance  FORMCHECKBOX  Select ALL in Category 2 FORMCHECKBOX Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. FORMCHECKBOX Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. FORMCHECKBOX Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. FORMCHECKBOX Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.Category 3 Engagement, Continuous Improvement and Accountability  FORMCHECKBOX  Select ALL in Category 3 FORMCHECKBOX Establish culturally and linguistically appropriate goals, policies and management accountability, and infuse them throughout the organizations planning and operations. 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FORMCHECKBOX Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery. FORMCHECKBOX Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area. FORMCHECKBOX Partner with the community to design, implement and evaluate policies, practices and services to ensure cultural and linguistic appropriateness. FORMCHECKBOX Create conflict- and grievance-resolution processes that are culturally and linguistically appropriate to identify, prevent and resolve conflicts or complaints. FORMCHECKBOX Communicate the organizations progress in implementing and sustaining CLAS to all stakeholders, constituents and the general public.     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