Attachments V and W - Special Event - Outreach Survey -

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Attachment V: Special Event/Outreach Survey (Professionals) (English)

Special Event/Outreach Survey (Professionals) (English)

Tasks and Time Line

Items in [brackets] are instructions for the CSR—they are not read to the respondent. The CSR does NOT read the response options unless the instructions explicitly instruct the CSR to do so. Otherwise, only the questions are read to the respondent.

Items in (parentheses) represent possible program-specific questions.

1. Are you: [CSR reads the response options]

1.	A medical professional [Continue with this survey]
2.	Representing a business or organization [Continue with this survey]
3.	Individual [Administer the survey for individuals]
4.	Refused to answer

2. What type of organization are you calling from?

1.	Medical Professional (doctor, nurse, medical librarian, medical association)
2.	Medical facility (hospital, clinic, HMO, long term care, institution [behavioral])
3.	Government (Federal, State, local, elected official)
4.	Health Department (State, local including county health clinic)
5.	International
6.	Law Enforcement/Early Responders (Police, fire, EMT)
7.	Military
8.	Veterinarian
9.	Education (schools, college, teacher, student, librarian, school nurse)
10.	Laboratory
11.	Law Firm (lawyers, professional corporation, ACLU)
12.	Organization/Association (not for profit, faith based, community based, environmental, health related [American Cancer Society])
13.	Business/Private Sector
14.	Correctional Facility
15.	Employee Assistance Program
16.	Other (specify) ________________________
17	Refused to respond

Public reporting burden of this collection of information is estimated to average of 5 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, and a person is not required to respond to a collection of information unless it displays a currently valid OMB 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-XXXX)

3. How did you hear about _________________(National HIV Testing Day) (National Infant Immunization Week) (World No Tobacco Day)?

1. Advertisement on TV or Radio
2.	TV ad
3.	Radio ad
4. Advertisement NOT on TV or Radio
5.	Billboard
6.	Bus ad (outside or inside)
7.	Magazine
8. Media
9.	Internet search
10.	Other web site
11.	CDC website
12.	Story line on TV program
	12a	Name of program:
13.	Other: ____________________
14.	Don’t recall
15.	Refused to answer

4. Is this the first time you have called CDC-INFO?

1.	Yes
2.	No
3.	Not sure
4.	Refused to answer

5. What did you learn from your call to CDC-INFO that you did not know before? (the responses will depend upon the nature of the campaign)

5. In the past 12 months, have you called CDC-INFO for materials or information about (HIV testing) (Immunization) (Smoking Cessation)? These may need to be modified for professionals

1.	Yes
2.	No
3.	Refused to answer

7. Finally, what do you think is the best way to get the word out about (HIV testing) (Immunization) (Smoking Cessation) in your community?

	Billboard				TV
	Bus ad (outside or inside)			Note to the Interviewer: If respondent selects TV as an option, fill in one of the following subcategories:
	Can’t think of anything
	Childcare/day care
	Clinic				News program
	Community agency				Commercial
	Doctor/other health care professional				Storyline on existing program
	Flyer	Note to the Interviewer: If respondent selects “storyline” as an option, ask “Which program/show?”
	Friend/family member					[Fill in name of show]:
	Grocery Store				WIC Nutritional Program for Women, Infants & Children
	Hospital				Other [Fill in]
	Information line				Refused to answer
	Internet/Website
	Magazine
	Newspaper
	Public Event
	Public Health Department
	Radio
	School

Those are all of the questions. Thank you for calling CDC-INFO. Goodbye.

Attachment W: Special Event/Outreach Survey (Professionals) (Spanish)

Special Event/Outreach Survey (Professionals) (Spanish)

Tasks and Time Line

Items in [brackets] are instructions for the CSR—they are not read to the respondent. The CSR does NOT read the response options unless the instructions explicitly instruct the CSR to do so. Otherwise, only the questions are read to the respondent.

Items in (parentheses) represent possible program-specific questions.

1. ¿Es usted: [CSR reads the response options]

1.	Un medico profesional [Continue with this survey]
2.	Representante de un negocio u organización [Continue with this survey]
3.	Individuo [Administer the survey for individuals]
4.	Refusa a responder

1. ¿De qué tipo de organización esta llamando?

1.	Medical Professional (doctor, nurse, medical librarian, medical association)
2.	Medical facility (hospital, clinic, HMO, long term care, institution [behavioral])
3.	Government (Federal, State, local, elected official)
4.	Health Department (State, local including county health clinic)
5.	International
6.	Law Enforcement/Early Responders (Police, fire, EMT)
7.	Military
8.	Veterinarian
9.	Education (schools, college, teacher, student, librarian, school nurse)
10.	Laboratory
11.	Law Firm (lawyers, professional corporation, ACLU)
12.	Organization/Association (not for profit, faith based, community based, environmental, health related [American Cancer Society])
13.	Business/Private Sector
14.	Correctional Facility
15.	Employee Assistance Program
16.	Other (specify) ________________________
17	Refused to respond

De acuerdo a gravámenes en informes públicos el promedio para recaudar ésta información es de 3 minutos por respuesta, lo cual incluye el tiempo utilizado para revisar instrucciones, buscar fuentes de datos ya existentes, recaudar y conservar datos necesarios, y completar y analizar la recaudación de la información. Una recaudación de información no debe llevarse a cabo o ser auspiciada por una agencia al menos que dicha recaudación lleve consigo un número actual de control OMB válido. De igual modo una persona no debe responder una recaudación de información si dicha recaudación no presenta un número actual de control OMB válido. Por favor sírvase enviar comentarios con respecto al estimado de este gravamen o de cualquier otro aspecto de ésta recaudación de información, también se pueden incluir sugerencias en cómo reducir este gravamen a CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333. ATTN: PRA (0920-XXXX)

3. ¿Cómo se entero acerca de _________________(Día Nacional de lucha contra el VIH) (Semana Nacional de la Inmunización infantil) (Día Mundial sin Tabaco)? Immunization

1. Advertisement on TV or Radio
2.	TV ad
3.	Radio ad
4. Advertisement NOT on TV or Radio
5.	Billboard
6.	Bus ad (outside or inside)
7.	Magazine
8. Media
9.	Internet search
10.	Other web site
11.	CDC website
12.	Story line on TV program
	12a	Name of program:
13.	Other: ____________________
14.	Don’t recall
15.	Refused to answer

4. ¿Es la primera vez que llamó a CDC-INFO?

1.	Yes
2.	No
3.	Not sure
4.	Refused to answer

4. ¿Aprendió algo nuevo como resultado de su llamada a CDC-INFO? ¿Obtuvo información que usted no sabia? (the responses will depend upon the nature of the campaign)

4. En los pasados 12 meses, ha llamado a CDC-INFO para pedir materiales o información sobre (prueba contra VIH) (Inmunización) (Dejar de fumar)? These may need to be modified for professionals

1.	Yes
2.	No
3.	Refused to answer

7. Finalmente, Cuál cree usted que sea la mejor manera de informar a su comunidad acerca de (Prueba contra VIH) (Inmunización) (Dejar de fumar)?

1	Billboard			20	TV
2	Bus ad (outside or inside)			Note to the Interviewer: If respondent selects TV as an option, fill in one of the following subcategories:
3	Can’t think of anything
4	Childcare/day care
5	Clinic				News program
6	Community agency				Commercial
7	Doctor/other health care professional				Storyline on existing program
8	Flyer	Note to the Interviewer: If respondent selects “storyline” as an option, ask “qué programa/show?”
9	Friend/family member					[Fill in name of show]:
10	Grocery Store		21		WIC Programa de Nutrición para Mujeres, Infantes y Niños
11	Hospital		22		Other [Fill in]
12	Information line		23		Refused to answer
13	Internet/Website
14	Magazine
15	Newspaper
16	Public Event
17	Public Health Department
18	Radio
19	School

Those are all of the questions. Thank you for calling CDC-INFO. Goodbye.