Data Collection Request Form

Attachment 10

Data Collection Request Form

Improving the Quality and Delivery of CDC’s Heart Disease and Stroke Prevention Programs

“Improving the Quality and Delivery of CDC’s Heart Disease and Stroke Prevention Programs”

Data Collection Request Form

Please complete the questions below and submit to Lauren Gase at [email protected]. Please attach a copy of the proposed data collection instrument.

Name of Project: __________________________________ Number: _________________

Point of Contact

Name: _______________________________________

Phone: _________________________ Email: _______________________________

Project Abstract

Please provide a brief overview of the project, including an explanation of the DHDSP training, technical assistance, or product being assessed and why is it a priority to assess the relevance, quality, and/or impact of this activity at this time. In addition, please identify what ways does this proposed data collection aligns with the purpose of the DHDSP plan and evaluation goals.

Time Frame

Please provide a brief timeframe for data collection and analysis

Data Collection System (check one)

• Phone Interview

• In-person Interview

• Phone Focus Group

• In-person Focus Group

• Web-based Survey

• Mixed (please explain): ________________________

Respondent Type (check all that apply)

• State Health Department Staff

• Nonprofit Organization Staff

• Public Health Organizations

• Professional Organizations

• Academic Institution

Number of Respondents

_

Total Number

_______State Health Department Staff

________Nonprofit Organization Staff

________Public Health Organization Staff

________Professional Organization Staff

________Academic Institution

Burden Hours

Number or respondent multiplied by the average time to complete the data collection

Number of Respondents Average time to complete data Total Burden Hours

collection

X =

Instrument

Are ALL questions contained instrument drawn VERMATIM from the Question Bank?

• Yes

• No – Requires amendment of clearance

The proposed data collection is consistent with the DHDSP plan and evaluation goals as outlined in 0920-XXXX.

____________________________ ________ Lauren Gase, DHDSP Contact Date

The proposed data collection conforms to the terms of the clearance as outlined in 0920-XXXX.

____________________________________ ________

Renita Macaluso, NCCDPHP OMB Contact Date

The Privacy Act applies

• Yes

• No

Approved as submitted

• Yes

• No

Changes

• Required

• Recommended

Project Number: ____________________________________ (Format: Year-Number)