Local Community Organization Survey

Subject ID: ________

Appendix C

Local Community Organization

Survey Instrument

Form Approved

OMB No.: 0920-xxxx

Exp. Date: xx/xx/xxxx

NYC HEALTH BUCKS EVALUATION

COMMUNITY ORGANIZATION SURVEY QUESTIONS

(FOR WEB SURVEY)

READ-IN FROM SAMPLE [PRE-POPULATED FROM ADMIN DATA]:

Name of Organization/Program:

Neighborhood(s) Served:

Name and Title of Person Completing Survey:

Email Address:

Phone Number:

You are being invited to take part in a survey that is being conducted as part of the evaluation of the New York City Health Bucks program. The survey will take about 10 minutes to complete.

SCREENER:

S1. Are you the individual (or one of the individuals) who was responsible for managing the distribution of Health Bucks for [COMMUNITY ORG NAME] this year?

• Yes

• No

IF NO:

S2. This survey should be completed by someone at [COMMUNITY ORG] who managed the distribution of Health Bucks for your organization this year.

Please provide the name and contact information for someone who managed the distribution of Health Bucks for your organization.

Name: _____________________________ Title: ______________________________

Email Address________________________ Phone Number______________________

We will contact this person directly. Thank you for your time!

Public reporting burden of this collection of information is estimated to average 10 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 Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-xxxx).

CONSENT [IN PRINTABLE FORMAT]:

INTRODUCTION

The New York City Health Bucks program gives out $2 coupons called “Health Bucks,” which shoppers can use to buy fresh fruits and vegetables in farmers’ markets in some New York City neighborhoods. Abt Associates Inc., a research consulting firm, is evaluating the Health Bucks program for the Centers for Disease Control and Prevention (CDC). As part of the evaluation, web-based surveys are being conducted with all community organizations that participated in the Health Bucks program, in order to help us understand your experiences with and opinions of the program this year. Your responses will also be used by the NYC Department of Health for tracking and planning purposes for the Health Bucks program.

RISKS OF TAKING PART IN THE STUDY

Completing this represents minimal risk to you and your organization. The primary risk is that your response to this survey could be disclosed in a way that identifies you or your organization; however, many procedures are in place to minimize this risk.

POSSIBLE BENEFITS OF TAKING PART IN THE STUDY

By completing this survey, you are helping us to understand how the Health Bucks program can be improved, and how programs like this might work in other communities. Lessons we learn from your responses will help to improve the program next year.

DATA SECURITY

Information collected as part of this survey will be maintained in a secure manner. Protections will be in place to safeguard your response to the maximum extent allowed by law. Your answers will be stored electronically in a secure location. Study researchers at Abt Associates, Inc., and the Health Bucks program staff at the NYC Department of Health will have designated access to study information for analysis purposes. Although CDC is sponsoring the study, the analysis plan does not call for sharing identifiable information with CDC, only information in summary form. For reporting and publication purposes, we plan to combine the comments and responses you give on the survey with the responses of about 200 other organizations.

PARTICIPATION IS VOLUNTARY

If you decide to participate in the survey, you will not be penalized in any way now or in the future based on your responses. Even if you agree to participate, you are not required to answer all the questions. In addition, a decision not to participate will not affect your relationship with CDC or the NYC Department of Health now or in the future.

QUESTIONS

You may call Lauren Olsho of Abt Associates Inc. (617-520-2326) or e-mail her at [email protected] to obtain more information. You may also call Teresa Doksum, IRB Administrator (617-349-2896) if you have other questions about your rights as a participant in this evaluation. Please note that calling these numbers will incur a toll.

STATEMENT BY PERSON COMPLETING THE SURVEY

By completing this survey, I agree that I have read and understand this information. I have had all my questions answered fully and I freely and voluntarily choose to participate in the survey.

I. Applying for Health Bucks

1. How did your organization first hear about Health Bucks? (Select one option.)

• Direct communication (email, phone call, mailing, flyer, in-person visit) from the District Public Health Office or the NYC Department of Health

• Another community organization that distributes Health Bucks

• Posters or other advertisements

• Newspaper ads or articles

• NYC Department of Health website

• Your organization’s clients or prior Health Bucks participants

• Some other way: ____________________________

2. Which of the following are reasons you wanted to distribute Health Bucks to recipients this year? (Check all that apply, and also choose the one reason you considered most important.)

• As an incentive to enroll in food stamps

• As an incentive to participate in a nutrition workshop or class

• As an incentive to participate in a non-nutrition workshop or class

• To encourage shopping at farmers’ markets

• To increase consumption of fruits and vegetables

• For use in outreach activities with our target population

• To supplement other farmers’ market coupons (e.g. WIC FMNP, cash or other supplements provided by your organization)

• Some other reason: _______________________________

3. Which of the following types of nutrition education or promotion activities did your organization provide in 2010? (Please check all that apply.)

• One-time nutrition education workshops or classes

• Ongoing nutrition education classes

• Nutrition or health events, such as health fairs

• Organized trip to farmers’ market

• One-on-one nutrition counseling

• Other: ___________________

OR [MUTUALLY EXCLUSIVE]

• None of the above – we did not provide nutrition education or promotion activities.

4. How easy or difficult was it for your organization to apply for Health Bucks this year? (Select one option.)

• Very easy

• Somewhat easy

• Neither easy nor difficult

• Somewhat difficult

• Very difficult

[IF RESPONDENT SELECTS SOMEWHAT OR VERY DIFFICULT IN Q4]

4a. What specifically made the Health Bucks application process difficult? [OPEN-END]

II. Distributing Health Bucks

5. In which of the following neighborhoods or boroughs did you distribute Health Bucks this year? (Please check all that apply)

• The Bronx

• Brooklyn

• Harlem

6. During which of the following months this year did you receive Health Bucks from your District Public Health Office? (Please check all that apply)

• April

• May

• June

• July

• August

• September

• October

• November

• December

• Don’t Know

7. During which of the following months this year did you distribute Health Bucks to recipients? (Please check all that apply)

[LIST ONLY MONTHS EQUAL OR LATER THAN FIRST RECEIVED HBs IN Q5]

• April

• May

• June

• July

• August

• September

• October

• November

• December

• Don’t Know

8. After you received your Health Bucks this year, did you:

• Distribute them mostly all at once, or

• Keep some to distribute throughout the farmers’ market season?

• Other (Please specify:_________________)

9. About how many of the Health Bucks you received in 2010 did you distribute?

• All

• More than half, but not all

• About half

• Some, but less than half

• None

[IF ANY CHECKBOX OTHER THAN “ALL” IS SELECTED IN Q9]

9a. Why didn’t you distribute all of your Health Bucks? (please check all that apply)

• Health Bucks received too early in the year

• Health Bucks received too late in the year

• Clients did not want Health Bucks

• Clients did not know about Health Bucks

• Forgot to distribute Health Bucks

• Did not have time to distribute Health Bucks

• Other:_______________________________

[LIST EACH CHECKED ACTIVITY IN Q3, OR SKIP TO Q12 IF “NONE” CHECKED]

10. Did you distribute Health Bucks this year during any of these nutrition education or promotion activities? (Please check yes or no for each activity.)

Activity	Health Bucks distributed?
[CHECKED ACTIVITY FROM Q1]	 Yes  No
[CHECKED ACTIVITY FROM Q1]	 Yes  No

[LIST EACH CHECKED ACTIVITY IN Q3, OR SKIP TO Q12 IF “NONE” CHECKED]

11. As a result of receiving Health Bucks to distribute in the community, did your organization add or expand nutrition education or promotion activities during 2010?

	Yes (Check all that apply.)		No, did not make any changes to these activities because of Health Bucks [MUTUALLY EXCLUSIVE]
Activity	Added new activities because of Health Bucks	Expanded existing activities because of Health Bucks
[INSERT CHECKED ACTIVITY FROM Q1]			
[INSERT CHECKED ACTIVITY FROM Q1]			

12. Did you receive enough Health Bucks to use in your organization’s programs as planned in 2010? (Select one option.)

• Yes

• No

13. Who did you distribute Health Bucks to this year? (Check all that apply)

• Children under 18

• Pregnant/parenting women

• Families (children and adults)

• Seniors

• Other adults not caring for children at home

• Other (specify): ________________

14. Did your organization have any requirements for recipients to qualify to get Health Bucks this year? (Select one option.)

• Yes

• No

14b. [IF YES]: Which of the following were requirements to get Health Bucks? (Check all that apply)

• Participation in the Food Stamp/SNAP program

• Low income

• Never or rarely shop at farmers’ markets

• High-risk health status (e.g. presence or risk of diabetes or other chronic diseases)

• Other: _____________________

15. Did your organization intentionally distribute Health Bucks this year:

Around the same time recipients’ Food Stamp/SNAP accounts were refilled? (Check one option.)

• Yes

• No

When you thought recipients’ Food Stamp/SNAP balance may be running low?

• Yes

• No

16. What is the highest number of Health Bucks that were given to a single person or household at one time this year?

______ Enter # of Health Bucks

• Not sure

17. What is the highest number of Health Bucks that were given to a single person or household over the course of 2010? (Enter highest number, or check “not sure.”)

______ Enter # of Health Bucks

• Not sure

III. Promoting and Tracking Use of Health Bucks

18. How did your organization advertise Health Bucks to increase awareness about the program this year? (Check all that apply)

• Brochures or flyers provided by the NYC Department of Health

• Posters provided by the NYC Department of Health

• Nutrition workshops or classes

• Non-nutrition workshops or classes

• Nutrition or health events, such as health fairs

• Talking directly to individuals

• Other: ____________________

• Did not advertise program [ANSWER OPTION MUTUALLY EXCLUSIVE].

19. When you distributed Health Bucks this year, did your organization regularly record any of the following information about recipients? (Check all that apply)

• Name

• Age

• Household size or number of children

• Household income

• Overall health status (e.g. presence or risk of diabetes or other chronic diseases)

• Participation in the Food Stamp/SNAP program

• Other: _________________

• No, did not collect information [ANSWER OPTION MUTUALLY EXCLUSIVE]

20. After distributing Health Bucks, how often did you follow up with recipients about:

	Always	Sometimes	Rarely	Never
If they used their Health Bucks				
What they bought with Health Bucks				
Where they used their Health Bucks				
Overall satisfaction with Health Bucks program				
Other: _____________________				

21. How did your organization encourage recipients to use Health Bucks?

• Handed out NYC Health Department brochures or flyers with Health Bucks

• Handed out Nutritional information with Health Bucks

• Provided cooking demonstrations for Health Bucks recipients

• Organized trips to farmers’ markets with Health Bucks recipients

• Discussed Health Bucks in nutrition education workshops or classes

• Followed up with individual Health Bucks recipients

• Other: ____________________

• None of the above [ANSWER OPTION MUTUALLY EXCLUSIVE]

22. How many recipients do you think used the Health Bucks you gave them?

• All

• Most

• Some

• None

22a. [IF ALL OR MOST]:

What do you think was most effective in getting recipients to redeem Health Bucks? [OPEN-END]

22b. [IF SOME OR NONE]:

Why do you think some recipients did not use them? [OPEN-END]

IV. Other Questions about Health Bucks

23. During the time your organization was distributing Health Bucks this year, approximately how many hours per week, on average, did organization staff spend on the distribution of Health Bucks and administration of the Health Bucks program?

• Less than 5 hours

• 5 to less than 10 hours

• 10 to less than 15 hours

• 15 to less than 20 hours

• 20 to less than 25 hours

• 25 hours or more

24. If you could change the way your organization distributed Health Bucks or administered the Health Bucks program this year, what would you change?

________________________________________________________________________

________________________________________________________________________

25. How satisfied were you with the Health Bucks program overall?

• Very satisfied

• Somewhat satisfied

• Neither satisfied nor unsatisfied

• Somewhat unsatisfied

• Very unsatisfied

26. Do you have any additional comments or feedback about the Health Bucks program?

________________________________________________________________________

________________________________________________________________________

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