The code block below illustrates how one might use # and // as comments in your logic and calculations.

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The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

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The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

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Required format:

J3MEAqGFJVRxJuaVD7FvE4RLzIVnwZ4Hs6ATyExL96C2ogo6QQ4cUkoKf

Health & Racial Equity Capacity Enrichment Request Form

Thank you for your interest in the Health & Racial Equity Capacity Enrichment Program. We will review your request within 10-business days.

Please note, that the Office of Diversity, Equity, Inclusion & Belonging will not be starting NEW training and consultation projects until February 3, 2025.

If interested, please complete the Capacity Enrichment Request Form.

Be well!

Office of Diversity, Equity, Inclusion & Belonging

Are you MDH Staff?

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Yes

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First and Last Name

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MDH Division

If other, please explain

Please identity your division's Health Equity Strategist (select one).

Organization Name

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Title

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Phone Number

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Address

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County

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Social Media Handles

Type of Request (Check all that Apply)

* must provide value

Technical Assistance (training or consulting) (examples include Health Equity 101 training, review of communications material)

Health Equity Coaching (facilitation of participant driven conversation and solutions)

Other

If other, please explain

Time Commitment

* must provide value

One-Time Request (e.g., one-time speaker request)

Short-term Request (meeting 2-3 times)

Ongoing Request (up to 4 months)

Other

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If other, please explain

Focus Area(s) (Check all that apply)

* must provide value

Community engagement

Data equity

Disability equity

Diversity, Equity, Inclusion, & Belonging (Office of DEIB)

Division of Health Equity, Strategy and Innovation

Equitable grantmaking

Health equity 101

Health equity 102

Health equity assessment

Imbedding equity in programs and policies

LGBTQIA+ equity

Racial equity

Communication

Systems change

Other

If other, please explain

Describe Your request

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Please desribe the project's goals for receiving a one-time speaker request, training, technical assistance or health equity coaching?

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Date of event (If applicable)

Deadline to respond to request

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D-M-Y

How did you learn about the Health & Racial Capacity Enrichment Program? (check all that apply)

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MDH internal Intranet message

Google-web-search

Learned from MDH staff

Center for Health Equity presentation

Learned from colleague or community partner

Other

If other, please explain

Are there any accessibility needs that MDH may support? Please explain.

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Additional Comments

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