Form 1 CDC National Prevention Information NetworkResource Orga

Information Collection of the Resources and Services Database of the National Prevention Information Network: 30 day

Final_0920_0255_att3-A_Init_Res_Org_Quest_Rev

Resources and Services Database of the CDC National Prevention Information Network - Initial Questionnaire Telephone Script: Registered Nurses

OMB: 0920-0255

Document [docx]
Download: docx | pdf



















Resources and Services Database of the CDC National Prevention Information Network



0920-0255





Attachment 3-A



Resource Organization Initial Questionnaire - Revised


Form approved

OMB No.0920- 0255

Exp. date: ­­__xx/xx/20xx


CDC National Prevention Information Network

Resource Organization Online Questionnaire



The National Prevention Information Network (NPIN) is a clearinghouse service provided by the U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention (CDC). A primary goal is to serve as a comprehensive source for information about organizations in the United States that provide services and resources related to HIV/AIDS-, Viral Hepatitis-, STD-, and TB-related infections. NPIN is authorized to collect this information by Section 301 of the Public Health Service Act (42 U.S.C. 241). This information is organized and maintained by the NPIN online database. The mission of NPIN is to serve the information needs of State and local HIV/AIDS/Viral Hepatitis/STD/TB program personnel and other professionals. The general public also has access to this information from the NPIN website (http://cdcnpin.org) or by calling CDC-INFO (formerly the CDC National AIDS and STD Hotline), which provides referrals from the NPIN database to local service organizations.


One of NPIN’s most pressing needs is to gather and update information about HIV/AIDS-, Viral Hepatitis-, STD-, and TB-related resources and services. The information you provide about your organization or program will be added to the CDC NPIN database and will be made available to professionals and other users. Your participation is voluntary.



Instructions


This Resource Organization Questionnaire is designed to help us learn as much information as we can about the services of your organization. It is comprised of 6 Sections. The first section (12 questions) is intended for all respondents to answer. The following 3 sections ask about your organization’s clients; direct services your organization provides to clients; and the education, information, and research services your organization provides. The final 2 sections inquire about access procedures and any additional comments. The Questionnaire is designed to cover many different types and sizes of organizations; therefore, some questions may not apply to your organization. A number of skip patterns allow you to by-pass sections of the Questionnaire that are not applicable to your organization.


Complete the Questionnaire online. Please note that the last section asks for your name and phone number. This information is important if we need to clarify your answers. Also, we urge you to attach electronic copies of information about your organization, particularly if additional space is needed to fully describe your services.


When completed, you may submit the Questionnaire online by clicking the Submit button. You may also print a hard copy of the completed questionnaire and return it to the following address or fax it to (888) 282-7681. For additional information, please call (800) 458-523l.


CDC National Prevention Information Network

Information Sciences Department

PO Box 6003

Rockville, MD 20849-6003



Public reporting burden of this collection of information is estimated to vary from 13-20 minutes per response, with average of 16 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, or 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0255).


IShape1 . ORGANIZATION INFORMATION



  1. Organization Name (including any department, division, or office). Attach your organization's letterhead, if possible.


_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________



2. Indicate the following (if any) by which your organization is known:

Acronym:_________________________________________________

Other name:______________________________________________

Previous name(s):________________________________________

Program name(s):_________________________________________



3. Organization's corporate address and mailing address, if different: (Include other site addresses on a separate sheet of paper and attach).

Corporate Address:

Street 1: ____________________________________________

Street 2: ____________________________________________

City: ________________________________________________

State:________________________________________________

County:_______________________________________________

Country: _____________________________________________


4. List your organization’s telephone number(s).


Main Telephone: (_____)__________________


Toll-Free: (___)_________________________


Fax: (_____)____________________________


Hotline: (___)___________________________


TDD/Deaf Access: (_____)_________________


Publications: (_____)_____________________


Spanish ( ) ________


Other ( ) _____________




5. List your organization’s Internet addresses.


E-mail Address: _______________________________________

Website Address: _______________________________________



6. Key staff (Please indicate (*) the name to whom mail should be addressed).

Name:________________________ Title:___________________ E-mail:__________________

Name:________________________ Title:___________________ E-mail: _________________

Name:________________________ Title:___________________ E-mail: _________________



7. Check the geographic area your organization serves, and specify name of area or jurisdiction.


Cities:______________________________________________

Counties:________________________________________________

States:__________________________________________________

Metropolitan Area:_______________________________________

Countries:_______________________________________________

Other:___________________________________________________




8. Is your organization a government agency?


 Yes  No




9. If your organization is non-government, check the description that best characterizes your organization:


For-Profit  Not-For-Profit  Not-For-Profit 501c3



10. Is your organization minority owned or operated?


 Yes  No




11. If your organization is not-for-profit, is it affiliated with a religion or religious denomination?


 Yes  No


If yes, which religion or denomination?

_________________________________________________________




12. What kinds of HIV/AIDS, Viral Hepatitis, STD, and/or TB work does your organization do?

_________________________________________________________

_________________________________________________________

_________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Shape2



II. CLIENT INFORMATION


1. Primary client groups your organization serves or targets.

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________



Shape3



III. CLIENT SERVICES OF YOUR ORGANIZATION


1. Does the organization provide services in languages other than English?  Yes  No

If yes, please specify: ___________________________________________________________




2. Does your organization provide direct services to clients who are infected or affected by HIV, STDs, TB or Viral Hepatitis?  Yes  No

IF NO, SKIP TO SECTION IV. IF YES, PLEASE ANSWER THE FOLLOWING QUESTIONS.



3. HIV ANTIBODY/Viral Hepatitis/STD/TB TESTING AND COUNSELING (Check terms that best describe your services)


HIV Test Counseling

Conventional Blood HIV Testing

Conventional Oral HIV Testing

Rapid Oral HIV Testing

Rapid Blood HIV Testing

Home HIV Test Kits

Partner notification

Mobile Testing

TB Testing

Viral Hepatitis

Testing

 Hepatitis A Testing

 Hepatitis B Testing

 Hepatitis C Testing

 Hepatitis C Rapid

Testing

STD Testing

Chlamydia Testing

 Syphilis Testing

 Gonorrhea Testing

 Herpes Testing

 Home STD Test Kits


4. TREATMENT (Check terms that best describe your services)

Clinical Trials

Medical Adherence Education and Counseling

Dental Care

Direct Observed Therapy (DOT) Short Course

Family Planning

HAV Immunizations

HBV Immunizations

HPV Immunization

Gynecological Care

Primary Care

STD Treatment

Viral Hepatitis

Treatment

Hepatitis B Treatment

Hepatitis C Treatment

TB Treatment

Other/Comments: __________________



5. HIV/AIDS Treatments and Therapies (Check terms that best describe your services)

Alternative/Complementary Medicine

HIV/AIDS Medical Treatment

Nutrition Therapy

Other/Comments: __________________



6. COUNSELING (Check terms that best describe your services)


Counseling

Sexuality Counseling

Substance Abuse Treatment



7. SUPPORT GROUPS  Yes  No



8. Does your organization provide any FAITH BASED AIDS SERVICES?

 Yes  No



9. SUPPORT SERVICES (Check terms that best describe your services)

 Case Management

 Food Services

 Child Care

 Home Care Assistance

Respite Care Services




Housing Services

Housing Opportunities for Persons with AIDS / HOPWA

Transportation Services



10. REFERRAL SERVICES  Yes  No



11. LEGAL SERVICES  Yes  No




12. FINANCIAL ASSISTANCE AND SERVICES TO INDIVIDUALS (Check terms that best describe your services)


Emergency Financial

Assistance

Housing Financial Assistance



Financial Assistance to

Individuals

Drug Purchasing Assistance, including AIDS Drug Assistance Programs (ADAP)




13. Does your organization provide funding to organizations?  Yes  No






IShape4 V. HOTLINE/INFORMATION/RESEARCH/EDUCATION SERVICES OF YOUR ORGANIZATION



1. Does your organization provide hotline, information, research, education, or advocacy services specific to HIV/AIDS, Viral Hepatitis, STDs, or TB?

Yes  No



IF NO, SKIP TO SECTION V. IF YES, PLEASE ANSWER THE QUESTIONS BELOW



2. HOTLINE SERVICES


2a. Does your organization operate a hotline?

 Yes  No

If no, please skip to Question 3.


2b. Is your hotline:


An AIDS hotline?  Yes  No

An STD hotline?  Yes  No

A TB hotline?  Yes  No

A viral hepatitis hotline?  Yes  No



If no to all of the above, please specify what type of hotline: _________________________________________________________




2c. Please describe the operation of the services provided by your hotline in the space below.



Type __Telephone # Type Telephone #________ ______________________________________________________________________________________________________________________________________________________­­­­­______________________



3. INFORMATION SERVICES (Check terms that best describe your services)

Electronic Information Resources

Materials – Print/Audiovisual)


Treatment Information



4. RESEARCH (Check terms that best describe your services)


Behavioral Research  Other Research



5. PREVENTION EDUCATION SERVICES (Check terms that best describe your services)


Curriculum Development

Conferences

 Safer Sex Education

Health Professional Education

 Hepatitis

Prevention/Education

HIV/AIDS Prevention/Education

Nutrition Education

Condom / Female Condom /Dental Dam Distribution

Needle Cleaning, Needle Exchange or Needle Distribution





Peer Education

Street Outreach

Public Awareness Campaigns

NAMES Quilt

Speakers Bureau

STD Prevention/Education

TB Prevention/Education

Training Programs

Train the Trainer

Abstinence Education

Capacity Building

Harm Reduction

Networking

Technical Assistance


6. Does your organization provide EVIDENCE-BASED BEHAVIORAL INTERVENTIONS?  Yes  No


If yes, please list the types of evidence-based behavioral interventions (level, risk category, race/ethnicity, sex/gender) provided:

________________________________________________________________________________________________________________________________________________________________________________________________




7. Does your organization provide EVIDENCE-BASED BEHAVIORAL INTERVENTION TRAINING?  Yes  No


If yes, please list the types of evidence-based behavioral intervention training (level, risk category, race/ethnicity, sex/gender) provided:

________________________________________________________________________________________________________________________________________________________________________________________________



8. Does your organization provide ONLINE TRAINING PROGRAMS?

 Yes  No


If yes, please list the online training programs provided:

________________________________________________________________________________________________________________________________________________________________________________________________



9. WORKPLACE PROGRAMS  Yes  No



10. PLANNING AND ADMINISTRATION (Check terms that best describe your services)


Program Administration

Advocacy/Activism

Community Planning

Grant Management




_Shape5


V. ACCESS PROCEDURES

Please check applicable items below and use the lines for explanation or additional information


1. Hours of operation

Please be specific: __________________________________________________________


2. Payment and Access


No Fee  Medicaid

Fee  Medicare

Fee Sliding Scale  Insurance

Donations Accepted  Free Testing

Appointment Required  Walk-ins Accepted

Other Restrictions: ________________________________________

Age Restrictions: __________________________________________


Free Testing:  Yes  No


If yes, please list the types of free testing (HIV, STD, Hepatitis B, or Hepatitis C) provided:

________________________________________________________________________________________________________________________________



3. Eligibility Requirements (or Restrictions): ________________________________________________________________________________________________________________________________






Shape6

VI. ADDITIONAL COMMENTS


The CDC National Prevention Information Network (CDC NPIN) and the CDC-INFO (formerly the CDC National AIDS Hotline) Hotline refer callers to organizations every day. We want to be certain that the information we provide about your organization is as complete as possible. Please provide any details about your organization that are not captured in this questionnaire. Feel free to attach written materials that describe your organization (e.g., brochure).

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________



Thank you for providing information about your organization. Please complete the following and sign this questionnaire. This information will be used for clarification purposes only and will not be included in the CDC National Prevention Information Network (NPIN) databases.


Your Name:______________________________________________________


Title or position:______________________________________________


Phone:__________________________________________________________


Date:___________________________________________________________


Signature: ________________________________________________________________



If you need help completing this questionnaire,

contact the CDC NPIN: (800) 458-5231.


4


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
Authorjmcintyre
File Modified0000-00-00
File Created2021-02-01

© 2024 OMB.report | Privacy Policy