Att E

Local

Agency Contribution Questionnaire

Local Public Health System Performance Assessment Instrument

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National Public Health Performance Standards Program
Local Public Health System Assessment Supplemental Questionnaire - Agency Contribution
Please use this questionnaire to indicate the contribution of the local health department to each model standard. The responses
to this questionnaire can be developed at the same time of the assessment or shortly thereafter.
Indicator
Number

Response
(please circle)

Question

Essential Service #1 - Monitor health status to identify health problems
A1.1

How much of this model standard - Population-based Community Health
Profile - is achieved through the direct contribution of the local health
department?

0-25% 26-50% 51-75% 76-100%

A1.2

How much of this model standard - Current Technology to Manage and
Communicate Population Health Data - is achieved through the direct
contribution of the local health department?

0-25% 26-50% 51-75% 76-100%

A1.3

How much of this model standard - Maintenance of Population Health
Registries - is achieved through the direct contribution of the local health
department?

0-25% 26-50% 51-75% 76-100%

Essential Service #2 - Diagnose and investigate health problems and health hazards
A2.1

How much of this model standard - Identification and Surveillance of Health
Threats - is achieved through the direct contribution of the local health
department?

0-25% 26-50% 51-75% 76-100%

A2.2

How much of this model standard - Investigation and Response to Public
Health Threats and Emergencies - is achieved through the direct contribution
of the local health department?

0-25% 26-50% 51-75% 76-100%

A2.3

How much of this model standard - Laboratory Support for Investigation
of Health Threats - is achieved through the direct contribution of the local
health department?

0-25% 26-50% 51-75% 76-100%

Essential Service #3 - Inform, educate and empower people about health issues
A3.1

How much of this model standard - Health Education and Promotion is achieved through the direct contribution of the local health department?

0-25% 26-50% 51-75% 76-100%

A3.2

How much of this model standard - Health Communication - is achieved
through the direct contribution of the local health department?

0-25% 26-50% 51-75% 76-100%

A3.3

How much of this model standard - Risk Communication - is achieved
through the direct contribution of the local health department?

0-25% 26-50% 51-75% 76-100%

Essential Service #4 - Mobilize community partnerships to identify and solve health problems
A4.1

How much of this model standard - Constituency Development - is achieved
through the direct contribution of the local health department?

0-25% 26-50% 51-75% 76-100%

A4.2

How much of this model standard - Community Partnerships - is achieved
through the direct contribution of the local health department?

0-25% 26-50% 51-75% 76-100%

Essential Service #5 - Develop policies and plans that support individual and community health efforts

82

A5.1

How much of this model standard - Governmental Presence at the Local
Level - is achieved through the direct contribution of the local health
department?

0-25% 26-50% 51-75% 76-100%

A5.2

How much of this model standard - Public Health Policy Development is achieved through the direct contribution of the local health department?

0-25% 26-50% 51-75% 76-100%

Local Public Health System Performance Assessment Instrument

Local

Indicator
Number

Question

Response
(please circle)

A5.3

How much of this model standard - Community Health Improvement Process
and Strategic Planning - is achieved through the direct contribution of the
local health department?

0-25% 26-50% 51-75% 76-100%

A5.4

How much of this model standard - Plan for Public Health Emergencies is achieved through the direct contribution of the local health department?

0-25% 26-50% 51-75% 76-100%

Essential Service #6 - Enforce laws and regulations that protect health and ensure safety
A6.1

How much of this model standard - Review and Evaluation of Laws,
Regulations and Ordinances - is achieved through the direct contribution
of the local health department?

0-25% 26-50% 51-75% 76-100%

A6.2

How much of this model standard - Involvement in the Improvement of Laws,
Regulations, and Ordinances - is achieved through the direct contribution
of the local health department?

0-25% 26-50% 51-75% 76-100%

A6.3

How much of this model standard - Enforcement of Laws, Regulations, and
Ordinances - is achieved through the direct contribution of the local health
department?

0-25% 26-50% 51-75% 76-100%

Essential Service #7 - L
 ink people to needed personal health services and assure the provision of health care when
otherwise unavailable
A7.1

How much of this model standard - Identification of Personal Health Service
Needs of Populations - is achieved through the direct contribution of the local
health department?

0-25% 26-50% 51-75% 76-100%

A7.2

How much of this model standard - Linkage of People to Personal Health
Services - is achieved through the direct contribution of the local health
department?

0-25% 26-50% 51-75% 76-100%

Essential Service #8 - Assure a competent public health and personal health care workforce
A8.1

How much of this model standard - Workforce Assessment, Planning and
Development - is achieved through the direct contribution of the local health
department?

0-25% 26-50% 51-75% 76-100%

A8.2

How much of this model standard - Public Health Workforce Standards is achieved through the direct contribution of the local health department?

0-25% 26-50% 51-75% 76-100%

A8.3

How much of this model standard - Life-Long Learning through Continuing
Education, Training and Mentoring - is achieved through the direct
contribution of the local health department?

0-25% 26-50% 51-75% 76-100%

A8.4

How much of this model standard - Public Health Leadership Development
- is achieved through the direct contribution of the local health department?

0-25% 26-50% 51-75% 76-100%

Essential Service #9 - Evaluate effectiveness, accessibility, and quality of personal and population-based health services
A9.1

How much of this model standard - Evaluation of Population-based Health
Services - is achieved through the direct contribution of the local health department?

0-25% 26-50% 51-75% 76-100%

A9.2

How much of this model standard - Evaluation of Personal Health Services - is
achieved through the direct contribution of the local health department?

0-25% 26-50% 51-75% 76-100%

A9.3

How much of this model standard - Evaluation of the Local Public Health
System - is achieved through the direct contribution of the local health
department?

0-25% 26-50% 51-75% 76-100%

Local Public Health System Performance Assessment Instrument

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Local

Indicator
Number

Question

Response
(please circle)

Essential Service #10 - Research for new insights and innovative solutions to health problems

84

A10.1

How much of this model standard - Fostering Innovation - is achieved through
the direct contribution of the local health department?

0-25% 26-50% 51-75% 76-100%

A10.2

How much of this model standard - Linkage with Institutions of Higher
Learning and/or Research - is achieved through the direct contribution of the
local health department?

0-25% 26-50% 51-75% 76-100%

A10.3

How much of this model standard - Capacity to Initiate or Participate
in Research - is achieved through the direct contribution of the local health
department?

0-25% 26-50% 51-75% 76-100%

Local Public Health System Performance Assessment Instrument