survey

FORM APPROVED

OMB Approval No. 0917-New

Exp. Date XX/XX/XX11

Indian Health Service Health Promotion/Disease Prevention

INTERVIEW SURVEY

REESI Inc. is evaluating the impact and effectiveness of the Indian Health Service (IHS) Health Promotion / Disease Prevention grant programs and is contacting all current and past IHS HP/DP grantees to complete the evaluation.  Please help IHS improve these programs by completing this short survey.  The telephone interview is expected to take 1 hour.

Category/Questions	Response Patterns 1=Strongly disagree 7=Strongly agree
Program Operations
We have/had no difficulty in meeting the administrative (hiring staff, training staff, planning, recruitment, preparing materials, budgets) objectives for our HPDP project.	1 2 3 4 5 6 7
We have the necessary resources (staff, money, equipment, facilities) etc. to carry out the program.	1 2 3 4 5 6 7
The goals that we set forth in our proposed intervention are/were realistic for our audience of focus.	1 2 3 4 5 6 7
Staff is/were knowledgeable about all aspects of the program (timelines, reports, objectives).	1 2 3 4 5 6 7
What comments would you like to share about the operations of your program?	Write comments. Verbally verify comments
Service Delivery
We are delivering/delivered the services we proposed to the intended audience.	1 2 3 4 5 6 7
Clients are/were aware of the services we offer(ed) through our funded HPDP program.	1 2 3 4 5 6 7
Clients are/were satisfied with the services they receive (d) from the funded HPDP program we offer(ed)	1 2 3 4 5 6 7
Clients would recommend other people for our HPDP program.	1 2 3 4 5 6 7
Clients have/had opportunities to offer feedback on how to improve the program (examples-surveys, conversations with staff or a suggestion box).	1 2 3 4 5 6 7
What comments would you like to share about your service delivery?	Write comments. Verbally verify comments
Program Outcomes
Our program data show that our outcome goals and objectives are being met/were met.	1 2 3 4 5 6 7
Our services for the funded HPDP program are reaching/reached the intended audience.	1 2 3 4 5 6 7
Clients have/had an improved quality of life after participating in our HPDP program.	1 2 3 4 5 6 7
Clients are more knowledgeable about their health and ways to improve their health since receiving services from our HPDP program.	1 2 3 4 5 6 7
Our program evaluation included measurable health outcomes in communities tied to Government Performance & Results Act (GPRA) or Performance Assessment Rating Tool (PART) performance measures.	1 2 3 4 5 6 7
What comments would you like to share about the outcomes of your programs and the impact it has had on participants?	Write comments. Verbally verify comments

Public Burden Statement: In accordance with Paperwork Reduction Act (5 CFR 1320.8 (b)(3), a Federal 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. Respondents must be informed (on the reporting instrument, in instructions, or in a cover letter) the reasons for which the information will be collected; the way the information will be used to further the proper performance of the functions of the agency; whether responses to the collection of the information are voluntary, required to obtain a benefit (citing authority), or mandatory (citing authority); and the nature and extent of confidentiality to be provided, if any (citing authority). Public reporting burden for this collection of information is estimated to average 1 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the necessary data, and completing and reviewing the collection information. Send comments regarding the burden estimate or any other aspect of this collection of information to the IHS PRA Information Collection Clearance Staff, 801 Thompson Ave., Suite 450, Rockville, MD 20852.

Indian Health Service Health Promotion/Disease Prevention

INTERVIEW SURVEY

Clients are more knowledgeable about their health and ways to improve their health since receiving services from our HPDP program.	1 2 3 4 5 6 7
Our program evaluation included measurable health outcomes in communities tied to Government Performance & Results Act (GPRA) or Performance Assessment Rating Tool (PART) performance measures.	1 2 3 4 5 6 7
What comments would you like to share about the outcomes of your programs and the impact it has had on participants?	Write comments. Verbally verify comments

Indian Health Service

Health Promotion/Disease Prevention

Evidence and Data Evaluation Checklist

The evaluator will request evidence data and information in advance of the interview in the following areas (linked to categories of questions in the interviews). Listed below is a checklist of information that will help guide grantees with preparing the information for the evaluation. It is anticipated that it will take 45 minutes to gather all the information.

	Program Operations
	Project position Descriptions (actual)	
	Project Organization Chart (actual)	
	List of partners and collaborations	
	Title and dollar amount of any supplemental funding	
	Service Delivery
	Dated Sign-In Sheets	
	Sample of participant registration forms	
	Sample of participant feedback forms	
	Sample outreach materials (one example from each method)	
	Program Outcomes
	Hard copies of major deliverables that were not included in the report	
	Evidence of the number of participants who actually completed the program	
	Pre-Post Test samples