Telephone Interview

<Form Approved

OMB No. 0920-0650

Exp. Date xx/xx/20xx

Telephone Interview for PRCs with Effective Interventions

PRC Indicator Data Collection

2010-2014 Funding Cycle

Questions for 2010

Identification Information

Interviewer:      

Name of PRC: Enter name using 50 or fewer characters PRC ID ###

Date interview conducted: mm/dd/yyyy

Name of PRC person participating in interview: Enter name

1. a. With the core funds your PRC received in fiscal year 2010 (October 1, 2009 through September 30, 2010), how many new people did you hire? [Note: include people whose job would have been eliminated without this funding (e.g., a person who was employed by the university--but not in the PRC—on hard or soft money, who would have lost their job had they not been hired through the PRC)]
   ##
   
   b. How many full-time equivalents (FTEs) did these new hires equal?
   ##
   
   

2. With the core funds your PRC received in fiscal year 2010, how many contracts did you enter into?
   ##
   
   

3. How many interventions, developed and/or tested by your PRC, were designated by an external group or agency (such as RTIPS or the Community Guide to Preventive Services) as an “effective intervention” during fiscal year 2010?
   ##
   
   
   To interviewer: If Q3 ≥ 1, ask questions 4-10 for each effective intervention. If Q3 = 0, the interview is complete—go to closing.
   
   

4. Briefly describe the intervention.
   Use 250 or fewer characters
   
   

Public reporting burden of this collection of information is estimated to average 1 hour 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).

5. With which type PRC project is the intervention associated?
   Core
   SIP
   Other
   
   

6. What is the name of the project with which the intervention is associated?
   Use 100 or fewer characters
   
   

7. What source(s) determined the intervention to be effective? (check all that apply)
   RTIPS
   Community Guide to Preventive Services
   PRC
   Other: Specify using 100 or fewer characters
   Other: Specify using 100 or fewer characters
   
   

8. What is the health focus of the intervention? (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 using 50 or fewer characters
   Not applicable (NA)
   
   

9. What type of intervention is this? (check all that apply)
   Programmatic (designed to change individual behavior; program delivery usually involves training the facilitator or implementer to deliver the program and ensure fidelity with the design)
   Policy/Environmental (the benefit to the individual derives from the context or environment they are in)
   Other: Specify using 50 or fewer characters
   
   

10. Has the intervention been adopted outside of the original study population?
    Yes
    No
    Don’t know
    
    

To interviewer: If the answer to question 10 is ‘Yes,’ continue with question 11; otherwise, ask questions 4-10 for the next effective intervention. If there are no more effective interventions, the interview is complete--go to closing.

11. For this intervention, please tell me each type of entity (e.g., organizations, agencies, communities) outside of the original study population that has adopted the intervention, and how many of each type entity adopted the intervention. If you do not know how many entities have adopted the intervention, please tell me you don’t know.
    
    

Type entity adopting the intervention	Number of entities adopting the intervention	Unknown number of entities (check if applicable)
a. Enter the type entity using 100 or fewer characters	#####
b. Enter the type entity using 100 or fewer characters	#####
c. Enter the type entity using 100 or fewer characters	#####
d. Enter the type entity using 100 or fewer characters	#####
e. Enter the type entity using 100 or fewer characters	#####

To interviewer: If there is another effective intervention, return to question 4. If there are no more effective interventions, the interview is complete.

Closing:

That’s all the questions I have. Thanks very much for your time.

3

Draft 7 3/24/2010