Web-based Survey

<Form Approved

OMB No. 0920-0650

Exp. Date xx/xx/20xx>

2010 Baseline PRC Indicator Survey

The purpose of this survey is to gather information that describes the work of the Prevention Research Centers (PRCs) in terms of their inputs, activities, outputs and outcomes. There are four sections in this survey: Collaboration, Other Research Projects, Training Programs, and Students Trained and Mentored. Your responses are essential to help us document your accomplishments and describe the PRC Program overall.

The survey should be completed by the most knowledgeable person. We appreciate the time needed to provide this important information.

Please provide contact information if clarification of responses is needed:
Enter name
Enter telephone #

Please select your University:

101 U of Alabama at Birmingham	115 Morehouse School of Medicine
102 U of Arizona	116 U of New Mexico
201 U of Arkansas for Medical Sciences	117 New York U
103 Boston U	118 U of North Carolina at Chapel Hill
104 U of California at Berkeley	205 Ohio State U
105 U of California at Los Angeles	119 Oregon Health & Science U
106 Case Western Reserve U	132 U of Pittsburgh
107 U of Colorado Denver	120 U of Rochester
108 Columbia U	121 St Louis U
202 Dartmouth College	122 San Diego State U
109 Emory U	123 U of South Carolina
110 Harvard U	124 U of South Florida
131 U of Iowa	125 Texas A&M Health Science Center
111 Johns Hopkins U	126 U of Texas Health Science Center at Houston
112 U of Kentucky	127 Tulane U
203 U of Maryland	128 U of Washington
204 U of Massachusetts Medical School	129 West Virginia U
113 U of Michigan	130 Yale U
114 U of Minnesota

COLLABORATION

This section asks about your PRC’s involvement with state or local health departments or other government agencies:

1. In fiscal year (FY) 2010 (October 1, 2009 through September 30, 2010), have your PRC faculty or staff members worked with any health departments or government agencies in any of the following capacities? (Check all that apply, or check “no work with this agency” at the bottom of each column if PRC faculty and staff did not work with health departments or a government agency in FY 2010.)

Capacity	State Health Dept	Local Health Dept	Other Government Agency (e.g., Indian Health Service)
a. Provided technical assistance
b. Served on boards or committees
c. One or more people from these agencies served on PRC boards or committees
d. Other: specify using up to 100 characters
e. Did not work with this agency in FY2010

2a. Did any of your PRC faculty or staff members co-author a scientific article with a local or state public health department employee that was published or will be published in calendar year 2010 (January – December)? (The article could have originated from either the PRC or the health department.)

Yes

No → Skip to Question 3

2b. How many such co-authored articles were actually published in calendar year 2010?

####

OTHER RESEARCH PROJECTS

This section asks about ‘other’ research projects (i.e., non-core, non-SIP research projects) within the scope of your PRC that were in progress during some or all of fiscal year 2010 (October 1, 2009 through September 30, 2010). DEFINITION: An “other” research project reflects a project for which PRC faculty or staff applied for and received funding from a foundation, government agency, or other funding source, for a defined project period.

3. How many ‘other’ (i.e., non-core, non-SIP) research projects were in progress during some or all of fiscal year 2010?

### → If ZERO Skip to Question 18; If MORE THAN ZERO answer questions 4-16 for each ‘other’ research project.

3. What is the title of the project? Use 200 or fewer characters 

3. In what month and year did this project start?

Month: MM

Year: YYYY

6a. Did the funding for this project end in fiscal year 2010?

Yes

No → Skip to Question 7

6b. In what month and year did it end?

Month: MM

Year: YYYY

7. What is the type of research (i.e., determinant, intervention/translation, methodological)? (Check all that apply.)
   DEFINITIONS:
   Determinant research examines how risk and protective factors affect health; tests hypotheses on the causality of behavioral or health outcomes.
   Intervention/translation research tests the efficacy, effectiveness, or impact of strategies or programs (interventions) in reducing disease and promoting health; examines dissemination or translation strategies for promoting the adoption, maintenance or adaptation of effective programs; may include assessing the effectiveness of programs in different settings or with different populations.
   Methodological research examines the reliability or validity of data collection or measurement instruments such as survey questions or the best methods to recruit participants; examines methods of analysis.
   
   Determinant → Skip to Question 9
   
   Intervention/Translation
   
   Methodological → Skip to Question 9
   
   Other (Specify: Use up to 100 characters ) → Skip to Question 9
   
   

8. What is the type of intervention (i.e., programmatic, policy/environmental)? (Check all that apply.)
   DEFINITIONS:
   Programmatic interventions are designed to change individual behavior; program delivery usually involves training the facilitator or implementer to deliver the program and ensure fidelity with program design.
   Policy/Environmental interventions benefit the individual through their context or environment.

Programmatic

Policy/Environmental

Other (Specify: Use up to 100 characters )

9a. Does this project focus on one or more health topics?

Yes

No → Skip to Question 10

9b. Which health topic is the focus of the project? (Check all that apply.)

Cancer
Heart disease or stroke
Respiratory diseases
Diabetes
Nutrition
Physical activity
Obesity and overweight
HIV/AIDS and STD prevention
Tobacco prevention and control
Injury and violence
Mental Health
Other (Specify: Use up to 30 characters )

10a. Does this project focus on people in particular age groups?

Yes

No → Skip to Question 11

10b. Which of the following age groups encompass the population of interest in the project? (Check all that apply.)

Infants and toddlers 0-3 years

Children 4-11 years

Adolescents 12-17 years

Young adults 18-24 years

Adults: 25-49 years

Older adults 50 years and over

11. Does this project focus on people of Hispanic or Latino origin?

Yes

No

12a. Does this project focus on specific racial groups?

Yes

No → Skip to Question 13

12b. Which races comprise the population of interest in the project? (Check all that apply.)

African American or Black

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

White

13a. Does this project focus on a vulnerable, hard-to-reach, or underserved group?

Yes

No → Skip to Question 14

13b. Which vulnerable, hard-to-reach, or underserved group is a focus of the study? (Check all that apply.)

Deaf or hard-of-hearing

Gay, lesbian, bisexual, transgender, questioning

Migrant, immigrant or refugee

Other (Specify: Use up to 50 characters )

14a. Is this project conducted in particular geographic locations (e.g., neighborhoods, cities/towns, counties/parishes, tribal nations, etc.)?

Yes

No → Skip to Question 15

14b. In which geographic locations is the project is conducted? (Check all that apply.)

Neighborhood

City/Town

County/Parish

Tribal Nation or Area

State

U.S.-Mexico Border

Other (Specify: Use up to 50 characters )

15a. Is this project conducted in particular sites (e.g., child care centers, homes, jails, clinics, schools, etc.)?

Yes

No → Skip to Question 16

15b. In which sites is the project is conducted? (Check all that apply.)

Child care center

Home

Jail or prison

Medical or clinical site

Place of worship

School or school district

Senior residence or center

University or college

Work site

Other

The next question requests information on the source(s) and amount of funding for this research project. A funding source is a foundation, government agency or other funding agency to which an investigator applies and receives funding for a defined project period.

16. What are the funding source(s) and dollar amounts for this project? (List the largest amount of funding first.)

Funding Source	Amount of annual direct funds
a1. Enter largest funding source	a2. Enter amount
b1. Enter 2nd largest funding source	b2. Enter amount
c1. Enter 3rd largest funding source	c2. Enter amount
d1. Enter 4th largest funding source	d2. Enter amount
e1. Enter 5th largest funding source	e2. Enter amount

16. Is there another research project in the ‘other’ category in progress during FY2010 to describe?
    

Yes → Go to Question 4

No → Continue to Question 18

TRAINING PROGRAMS

This section asks about formal training programs. A formal training program usually has a syllabus, is comprised of one or more sessions, and is generally intended to be implemented more than once. It is distinguished from an ad hoc lecture or discussion that meets an immediate need and then is finished.

16. How many different formal training programs (i.e., programs with different content) did the PRC deliver or implement during fiscal year 2010? (not how many times did they repeat the same training program)

### If ZERO Skip to Question 21; If MORE THAN ZERO answer questions 19 and 20 for each different formal training program that the PRC delivered or implemented during fiscal year 2010.

19a. What is the title of the formal training program? (Use 100 or fewer characters.)

19b. Formal training programs may reach a variety of different types of audiences. For the formal training program in Q19a, list the total number of people trained in fiscal year 2010 for each of the following audience types. (If no one in a particular audience type was trained in FY 2010, enter 0.)

Audience Type	Total # of people trained in FY2010
1. Academic faculty or other researchers	###
2. Community members	###
3. Community agency or other non-governmental organization representatives	###
4. Health care practitioners	###
5. Public health employees	###
6. Public health students	###
7. Other	###

20. Is there another formal training program implemented in FY2010 to describe?

Yes → Go to Question 19

No → Continue to Question 21

STUDENTS TRAINED OR MENTORED

This section asks about the number of students that were trained or mentored by the PRC faculty and staff during FY2010 by type of student. DEFINITION: Training indicates the transferring of knowledge, skills and competencies; mentoring indicates a sustained relationship between two people in which the mentor strives to increase the mentee’s self-confidence and skills.

20. How many students in each academic category below were trained or mentored by the PRC during FY2010? (Do not include students who only participated in formal training programs referenced in question 18 above. If the PRC did not train or mentor anyone in one or more of the academic categories, please enter 0.)

Student category	Number of students trained or mentored by the PRC in FY2010
a. How many high school students were trained or mentored?	###
b. How many undergraduate students were trained or mentored?	###
c. How many masters students were trained or mentored?	###
d. How many doctoral students were trained or mentored?	###
e. How many post-doctoral students were trained or mentored?	###

Thank you for your time and attention in completing this survey!

1 Draft 2 2/25/2010

Public reporting burden of this collection of information is estimated to average 6 hours 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0650).