Appendix D: Questionnaire (Telephone Script)

Appendix D

Questionnaire (Telephone Script)

**Note: All proposed changes in the attached are highlighted in gray.

Form Approved

OMB No.0920- 0255

Exp. date: ­­__xx/xx/20xx

CDC National Prevention Information Network

Questionnaire (Telephone Script)

Public reporting burden of this collection of information is estimated to average of 17 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, or respond to a collection of information unless it displays a currently valid 0MB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0255).

CDC National Prevention Information Network

Questionnaire (Telephone Script)

Hello, my name is _______________________ and I am calling from the CDC National Prevention Information Network.

The National Prevention Information Network (NPIN) is a clearinghouse service provided by the U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention (CDC). A primary goal of NPIN is to serve as a comprehensive source for information about organizations in the United States that provide HIV/AIDS-, Viral Hepatitis-, STD-, and TB-related services or resources. The clearinghouse is authorized to collect this information by Section 301 of the Public Health Service Act (42 U.S.C 241). This information is organized and maintained by the NPIN online database. The mission of NPIN is to serve the information needs of state and local HIV/AIDS/Viral Hepatitis/STD/TB program personnel and other professionals. The general public also has access to this information from the NPIN website or by calling CDC-INFO (formerly the CDC National AIDS and STD Hotline), which provides referrals from the NPIN database to local service organizations.

We have identified your organization as providing services or resources related to HIV/AIDS, Viral Hepatitis, STDs, and/or TB and I am calling to obtain information about your organization and its services. The information you provide about your organization or program will be added to the NPIN database and will be made available to professionals and other users. Your participation is voluntary.

Are you willing to participate in this data collection at this time?

To Interviewer: If respondent says ‘yes’, continue with questionnaire. If respondent replies ‘no’, thank respondent for their time and end call.

I. ORGANIZATION INFORMATION

1. Please tell me your organization’s name, including any department, division or office.

___________________________________________________________________________

_________________________________________________________________________________

2. Does your organization have (use) an acronym for your company name? If yes, what is it?

Acronym: __________________________________________________________________

3. Is your organization known by any other name? If yes, what is it?

Other name: __________________________________________________________________

Previous name(s):__________________________________________________________________

Program name(s):__________________________________________________________________

4. What is the street address for your organizations?

Street 1: ____________________________________________________________________

Street 2: ____________________________________________________________________________

City: ____________________________________________________________________

State: ____________________________________________________________________

ZIP: ____________________________________________________________________

County: ____________________________________________________________________

Country: ____________________________________________________________________

4. Does your organization have a different mailing address? If so, what is it?

Organization's corporate address and mailing address, if different: (Include other site addresses on a separate sheet of paper and attach).

Street 1: _______________________________________________________

Street 2: _______________________________________________________

City: _______________________________________________________

State: _______________________________________________________

ZIP: _______________________________________________________

County: _______________________________________________________

Country: _______________________________________________________

4. Please tell me your main phone number and your fax number? Does your organization have a toll-free number, a TTD number, a hotline number, or a Spanish-speaking number? Are there any other phone numbers we should have?

Main Telephone :(______) ______________________________________________________

Fax: (______) ________________________________________________________________

Toll-Free: (______) ____________________________________________________________

Hotline: (______) ______________________________________________________________

TDD/Deaf Access: (______) ______________________________________________________

Spanish: (______) ______________________________________________________________

Publications: (______) __________________________________________________________

Other: (______) ________________________________________________________________

4. Does your organization have an e-mail address? A website?

E-mail Address: ____________________________________________________________________

Website Address: ___________________________________________________________________

4. Please tell me the name(s) of key staff to contact for updating your organization’s information. Please provide the title, and email address. This information is only used internally and is not released to the public.

Name: __________________Title:_______________________E-mail: _______________________

Name: __________________Title:_______________________E-mail: _______________________

Name: __________________Title:_______________________E-mail: _______________________

4. What geographic area(s) does your organization serve?

Cities: ____________________________________________________________________________

Counties:__________________________________________________________________________

States: ____________________________________________________________________________

Regions:__________________________________________________________________________

Countries:_________________________________________________________________________

Other: ____________________________________________________________________________

4. Is your organization non-profit, governmental, or commercial? _____________________________________

[To interviewer: if respondent answers governmental or commercial, skip to Question 12.]

4. If your organization is non-profit, does it have 501c3 status? ________________________________________

12. If your organization is not-for-profit, is it affiliated with a religion or religious denomination?

Yes No

If yes, which religion or denomination? ________________________________________________________________

13. Is your organization minority owned or operated?

Yes No

14. What kinds of HIV/AIDS, Viral Hepatitis, STD, and/or TB work does your organization do?

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

II. CLIENT INFORMATION

1. What are the primary client groups your organization serves or targets?

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

III. CLIENT SERVICES OF YOUR ORGANIZATION

1. Does your organization offer services in any language other than English? Yes No

If yes, what languages? _______________________________________________________________________________

2. Does your organization provide direct services to clients who are infected or affected by HIV, STDs, or TB? Yes No

[TO INTERVIEWER, IF RESPONDENT ANSWERS NO, SKIP TO SECTION IV.]

3. What disease testing services does your organization offer?

[TO INTERVIEWER: Read choices and check services offered by organization.]

Anonymous HIV-Antibody Testing Services

Anonymous HIV Test-related Counseling

Confidential HIV-Antibody Testing Services

Confidential HIV Test-related Counseling

HIV-Test Related Counseling

Partner notification

Oral testing

Rapid oral testing

Rapid blood testing

Home test kits

Anergy testing

Viral load testing

STD Testing

TB Testing

Viral hepatitis testing

Hepatitis B testing

Hepatitis C testing

4. What medical treatment services does your organization offer?

[TO INTERVIEWER: Read choices and check services offered by organization.]

Dental Care

Direct Observed Therapy (DOT) Short Course

Eye Care

Family Planning

Health Fairs

Immunizations

• HAV Immunizations

• HBV Immunizations

• HPV Immunization

Infusion Therapy

Mobile Health Services

OB / GYN Care

 Gynecological Care

• Obstetrics

• Prenatal Education and Counseling

• Occupational Therapy

• Pediatric Care

• Well Baby Care

• Physical Therapy

• Primary Care

• Respiratory Therapy

School Clinics

 College Health Services

Speech Therapy

STD Treatment

TB Treatment

Viral hepatitis treatment

Hepatitis B treatment

Hepatitis C treatment

Worksite Clinics

Other/Comments: ____________________

5. What HIV/AIDS treatments and therapies does your organization offer? [TO INTERVIEWER: Read choices and check services offered by organization.]

Alternative Therapies

 Acupuncture

 Aroma Therapy

 Art Therapy/ Music Therapy / Dance Therapy

 Chiropractic Therapy

 Herbal Therapy

 Holistic Therapy

 Homeopathic Therapy

 Massage

 Meditation

 Nutrition Therapy

 Traditional Chinese Medicine

Clinical Trials

Drug Therapy

Combination Therapy

Other/Comments: _____________________

6. What counseling or mental health services does your organization offer? [TO INTERVIEWER: Read choices and check services offered by organization.]

Abstinence Counseling

Bereavement Counseling

Caregiver Counseling

Crisis Intervention Counseling

Family Counseling / Couples Counseling

Group Counseling

Individual Counseling

Safer Sex Counseling

Sexual Abuse Counseling

Sexuality Counseling

Stress Management Counseling

Mental Health Counseling

Substance Abuse Counseling

7. Does your organization offer any support services? Yes No

If yes, what types of support groups are offered?

_________________________________________________________________________________

8. What spiritual services does your organization offer? [TO INTERVIEWER: Read choices and check services offered by organization.]

Faith Based AIDS Services

Clergy Education

Parishioner Education

Spiritual Counseling / Pastoral Counseling

Spiritual Retreats

9. What support services does your organization offer?

[TO INTERVIEWER: Read choices and check services offered by organization.]

Adult Day Care for Persons with HIV/AIDS

Advocacy

Case Management, Administration

Buddy Programs

Child Services

 Adoption Services

Child Day Care Services

Foster Care Services

Clothing Banks

Food Services

Emergency Food Services/Soup Kitchens

Food Banks/Pantries

Meal Preparation and Home Delivery

Funeral Planning Assistance

Home Health Aides Services

Home Skilled Nursing Care

Homemaker Services

Personal Care Services

Pet Care Services

Respite Care Services

Hospice Services

Housing Services

Assisted Living Services

Emergency Housing Services

Housing Opportunities for Persons with AIDS / HOPWA

Medical Supplies and Equipment Services

Recreational and Social Program Services

Transportation Services

Visiting Programs

10. What referral services does your organization offer?

[TO INTERVIEWER: Read choices and check services offered by organization.]

Counseling Referral

Legal Referrals

Medical Referrals

HIV Antibody Testing Referrals

STD Testing Referrals

TB Testing Referrals

Viral Hepatitis Vaccination Referrals

Viral Hepatitis Testing Referrals

Social Services Referrals

Financial Referrals for Individuals

Housing Referrals / Shelter Referrals

11. What legal assistance services does your organization offer?

[TO INTERVIEWER: Read choices and check services offered by organization.]

Estate Planning and Wills

Immigration Legal Services

Litigation Support

Powers of Attorney

12. What financial assistance and services does your organization offer? [TO INTERVIEWER: Read choices and check services offered by organization.]

Emergency Financial Assistance

Funeral Financial Assistance

Housing Financial Assistance

Insurance Financial Assistance

Personal Financial Planning

Pharmacy Assistance Services

Drug Purchasing Services

Mail Order Drug Services

Viatical Settlements

Funding

Fundraising

13. What financial services do you offer to organizations?

[TO INTERVIEWER: Read choices and check services offered by organization.]

Funding

Fundraising

 Grant Management

I V. HOTLINE/INFORMATION/RESEARCH/EDUCATION SERVICES OF YOUR ORGANIZATION

1. Does your organization provide hotline, information, research, education, or advocacy services specific to HIV/AIDS, Viral Hepatitis, STDs, or TB?

Yes No

[TO INTERVIEWER: IF NO, SKIP TO SECTION V.]

2. HOTLINE SERVICES

2a. Does your organization operate a hotline? Yes No

2b. Is your hotline:

An AIDS hotline? Yes No

An STD hotline? Yes No

A TB hotline? Yes No

A viral hepatitis hotline? Yes No

If no, what type of hotline do you operate? ________________________________________________________________

2c. What kinds of services are provided by your hotline? What is the hotline number?

Type Telephone #__________________

___________­­­­­­­­­­­­­­­­­­­________________________________________________________________

____________________________________________________________________________

3. What information services are offered by your organization? [TO INTERVIEWER: Read choices and check services offered by organization.]

Electronic Information Resources

Information Dissemination

Audiovisual Materials Dissemination

Print Materials Dissemination

Treatment Information Dissemination

Library Services and Resource Centers

Materials Production

Audiovisual Materials Production

Newsletter Publication / Circulation

Print Materials Production, Databases

Networking

4. What kind of research does your organization conduct?

[TO INTERVIEWER: Read choices and check services offered by organization.]

Behavioral Research

Contact Tracing

Data Analysis

Epidemiological Reporting

Pediatric AIDS Research

Pharmaceutical Research

Vaccine Development Research

Surveillance

5. What kind of educational services does your organization offer? [TO INTERVIEWER: Read choices and check services offered by organization.]

Curriculum Design / Curriculum Development

Conferences

Emergency Medical Technician Education

Health Education

Safer Sex Education

School or University Education

Health Professional Education

Nurse Education

Physician Education

Viral Hepatitis Prevention

HIV/AIDS Prevention

Intervention Strategies

Nutrition Education

Outreach

Bleach Distribution

Condom / Female Condom / Dental Dam Distribution

Needle Cleaning or Needle Sterilization

Needle Exchange or Distribution

Peer Education

Street Outreach

Parent Education

Partner Communication

Patient Education

Provider Education

Public Awareness Campaigns

NAMES Quilt

Speakers Bureau

STD Prevention

TB Prevention

Training Programs

Buddy Training

Caregiver Training

Continuing Education

Train the Trainer

Volunteer Training

6. What kind of workplace programs does your organization offer? [TO INTERVIEWER: Read choices and check services offered by organization.]

 Americans with Disabilities Act / ADA

 Employee assistance programs

Employee education

Employment Counseling

Employment Training

Managers / Supervisors Education

Occupational Safety and Health

Return to Work Programs

Technical Assistance

Union Training

7. What health care planning services does your organization offer?

[TO INTERVIEWER: Read choices and check services offered by organization.]

HIV/AIDS Program Administration

State/Regional Planning or Coordination

Policy Analysis or Recommendation

HIV/AIDS Activism

8. Does your organization produce HIV/AIDS education and prevention newsletters or other materials?

 Yes  No

If yes, ask what types of materials are offered?

Newsletter

Title: ______________________________________

Frequency: ______________________________________

Other Print materials ______________________________________

Audiovisual materials ______________________________________

V. ACCESS PROCEDURES.

Please check applicable items below and use the lines for explanation or additional information

1. What are your business (service) hours?

____________________________________________________________________________

2. Does your organization require appointments? Are walk-ins accepted?

 Appointment required  Walk-ins accepted

3. Are fees charged for services? If yes, does your organization offer a sliding fee scale?

 No fee.

 Fee.

• Fee. Sliding scale.

4. Does your organization accept Medicaid, Medicare, and Insurance?

 Medicaid  Medicare

 Insurance

5. Does your organization offer free HIV testing?  Yes  No

6. Does your organization accept donations?   Yes  No

7. Is your organization handicapped accessible?  Yes  No

8. Are there any restrictions on eligibility (for services)? If so, what kinds of restrictions do you enforce?

_____________________________­­­­­­­­­­­­­­­­­­­­­­­­­____________________________________

V I. ADDITIONAL COMMENTS

The National Prevention Information Network (NPIN) and the CDC-INFO (formerly the CDC National AIDS Hotline) Hotline refer callers to organizations every day. We want to be certain that the information we provide about your organization is as complete as possible. Are there any other details about your organization that have not been captured in this questionnaire?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Thank you for completing this survey! We appreciate your time and effort.