Heart Disease and Stroke Prevention Programs

Division for Heart Disease and Stroke Prevention Management Infromation System (formerly titled: Cardiovascular Health Branch Management Information System)

CHB MIS Data Collection Tool

Heart Disease and Stroke Prevention Programs

OMB: 0920-0679

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PowerPlusWaterMarkObject3 DACH HDSP MIS 1.0

Data Collection


Revision History

Date

Changes

By Whom:

05/25/04

Original document.

J Casner

02/05/07

2007 Enhancements and WISEWOMAN Program Updates

Alison Knight

Overview

The following table defines the data proposed for collection through the CDC Heart Disease and Stroke Prevention and WISEWOMAN Information System (HDSP IS). For each key section, the question and response options are identified. If the response option is labeled “text”, the responder can enter free form text. * indicates a required field. “(WW)” indicates information that is specific to the WISEWOMAN program. “(HDSP)” indicates information that is specific to the HDSP program.

Information Sections

The data collected is grouped according to the key sections listed below.


Program Information

Question

Response Options

Program Name

  • Text

Grant Number

  • Text

Program Type

  • Display only

Primary Program Telephone

  • Text

Business Official

  • Text

Mailing Address Line 1

  • Text

Mailing Address Line 2

  • Text

Mailing City

  • Text

Mailing State

  • Select state from list

Mailing Postal Code

  • Text

Shipping Address Line 1

  • Text

Shipping Address Line 2

  • Text

Shipping City

  • Text

Shipping State

  • Select state from list

Shipping Postal Code

  • Text

Program Web Address

  • Text

Program Fax

  • Numeric


Key Personnel

Question

Response Options

First Name *

  • Text

Middle Name

  • Text

Last Name *

  • Text

Telephone *

  • Text

E-mail Address *

  • Text

Primary Role *

  • Select one:

  • Administrative Support

  • Communication Specialist

  • Community Health Advisors

  • Data Manager (WW)

  • Data Management Staff (WW)

  • Epidemiologist

  • Evaluator

  • Health Educator

  • Health Systems Specialist

  • Lifestyle Intervention Specialist (WW)

  • Nutrition Coordinator (WW)

  • Physical Activity Coordinator (WW)

  • Policy Analyst

  • Program Coordinator

  • Program Director

  • Program Manager

  • Other (specify)

Secondary Role (WW)

  • Select one:

  • Administrative Support

  • Communication Specialist

  • Community Health Advisors

  • Data Manager (WW)

  • Data Management Staff (WW)

  • Epidemiologist

  • Evaluator

  • Health Educator

  • Health Systems Specialist

  • Lifestyle Intervention Specialist (WW)

  • Nutrition Coordinator (WW)

  • Physical Activity Coordinator (WW)

  • Policy Analyst

  • Program Coordinator

  • Program Director

  • Program Manager

  • Other (specify)

Program Time Allocation *

  • Percentage

Percentage of Salary paid by CDC DHDSP

  • Percentage

Is this individual a contractor? *

  • Select one:

  • Yes

  • No

Is this individual the primary program contact? *

  • Select one:

  • Yes

  • No

Personnel Attachments Title*

  • Text – file name

Date Revised*

  • Date

Type of Evidence*

  • Select one:

  • Resume

  • CV

  • Other (Specify)

Other (specify)

  • Text


Key Partners

Question

Response Options

Partner Type*

    • Select one:

    • Academia (university or college)

    • Community based organization (WW)

    • Community health center (FQHC) (WW)

    • District or local government agency (WW)

    • Faith based organization

    • Healthcare Organization

    • Organization Representing Priority Population(s)

    • Other State Government Entity

    • Private sector business

    • State Health Department Programs

    • Voluntary agencies or professional organizations

    • Other (specify)

Other (specify)

  • Text

Partner Name*

  • Text

Partner Contact Name*

  • Text

Is this partner a member of the statewide work group responsible for the comprehensive CVH State plan*

    • Select one:

    • Yes

    • No

Upload Evidence of Commitment*

  • Text – file name

Type of Evidence

  • Select one:

    • Letters of support

    • Memorandum of Understanding

    • Other (specify)

Other (specify)

  • Text


Key Contractors

Question

Response Options

Organization Name*

  • Text

Contact Name

  • Text

Primary Role*

    • Select one:

  • Communication

  • Communication/Marketing (WW)

  • Data Management (WW)

  • Epidemiologist

  • Evaluator

  • Health Educator

  • Health Systems Specialist

  • Information Technology Specialist (WW)

  • Lifestyle Intervention Service Delivery(WW)

  • Policy Analyst

  • Program/Intervention Development (WW)

  • Screening Service Delivery (WW)

  • Other (specify)

Secondary Role*

    • Select one:

  • Communication

  • Communication/Marketing (WW)

  • Data Management (WW)

  • Epidemiologist

  • Evaluator

  • Health Educator

  • Health Systems Specialist

  • Information Technology Specialist (WW)

  • Lifestyle Intervention Service Delivery(WW)

  • Policy Analyst

  • Program/Intervention Development (WW)

  • Screening Service Delivery (WW)

  • Other (specify)

Other (specify)

  • Text

Amount of Contract Funded by CDC CVH *

  • Percentage


State Plan (HDSP)

Question

Response Options

Title*

  • Text

Plan Timeframe*


  • Dates

Status*

  • Select one:

  • Draft

  • Published

Website Address

  • Text

State Planning Group Name

  • Text

List Subgroups

  • Text

State Plan Attachments Title*

  • Text – file name

Type of Evidence

  • Select one:

  • Meeting Agenda or Minutes

  • State Plan

  • Other (specify)

Other (specify)

  • Text


Burden Report (HDSP)

Question

Response Options

Your state’s burden report is currently:

  • Select one:

  • Published

  • Unpublished

Title*

  • Text

Publish Date*

  • Month and year

Report Focus*

  • Select one:

    • Heart Disease

    • Stroke

Date hard copy sent to CDC*

  • Month and year

Priority Populations:

Gender*


  • Select one:

  • Female

  • Male

  • Not Specific

Geography*

  • Select all that apply:

  • Rural / Low Density

  • Urban / High Density

  • Not Specified

Race *


  • Select up to 3:

  • American Indian or Alaska Native

  • Asian

  • African American or Black

  • Native Hawaiian or other Pacific Islander

  • White

  • Not Specified

Ethnicity*

  • Select all that apply:

  • Hispanic or Latino

  • Not Hispanic or Latino

  • Not Specific

Socioeconomic Status (SES)*

  • Select one:

  • Low

  • Not Specified

Additional Population Comments

  • Text

Burden Report Web Address

  • Text - URL

Upload Burden Report(s): Document Title

  • Text – file name

Date Last Revised

  • Month and year

Working Report Title*

  • Text

Anticipated Publish Date*

  • Month and year

Describe Progress to Date*

  • Text


Standard Data Sources

Question

Response Options

Standard Data sources*

  • Select one or more:

    • BRFSS Alcohol Consumption Module (WW)

    • BRFSS Cardiovascular Disease Module

    • BRFSS Cholesterol Awareness Module

    • BRFSS Core Modules (WW)

    • BRFSS Fruits and Vegetables Module (WW)

    • BRFSS Healthy Days Module (WW)

    • BRFSS Heart Attack and Stroke Module (WW)

    • BRFSS Heart Disease and Stroke Signs and Symptoms Module

    • BRFSS Hypertension Awareness Module

    • BRFSS Other Tobacco Products Module (WW)

    • BRFSS Physical Activity Module (WW)

    • BRFSS Quality of Life Module (WW)

    • BRFSS Smokeless Tobacco Module (WW)

    • BRFSS Tobacco Use Prevention Module (WW)

    • BRFSS Weight Control Module (WW)

    • Centers for Medicare and Medicaid Services (CMS)

    • Health Care Organization

    • Health Plan Employer Data and Information Set (HEDIS)

    • Hospital Discharge Data

    • Indian Health Service (WW)

    • U.S. Bureau of Census

    • Vital statistics

    • WISEWOMAN Minimum Data Elements (WW)

    • Youth Risk Behavior Surveillance (YRBS)

    • Other (specify)

Other (specify)

  • Text

Most Recent Data Set Year (YYYY)*

  • Year


Other Data Sources

Question

Response Options

Data Source Name*

  • Text

Describe Population Sampled*

  • Text

Describe Collection Method*

  • Text

Collection Frequency*

  • Select one:

    • Single Collection

    • Ongoing Collections

Most Recent Year Collected*

  • Year


Policy and Environmental Assessments (HDSP)

Question

Response Options

Title*

  • Text

Assessment Type*

Select one:

  • State level

  • District level

Assessment Setting*

Select one:

  • Health Care

  • Work Site

  • Community

  • School

Last Assessment Date*

Enter Date

Summarize the data collected in the assessment*

  • Text

Summarize the methods used for the assessment*

  • Text

Summarize the findings of the assessment*

  • Text

Attachments

  • Upload File




Intervention Long Term Objective

Question

Response Options

Objective Title*

  • Text

Objective Description*

  • Text

Status*

  • Select one:

  • Planned

  • In Process

  • Completed

  • Cancelled

  • Deferred

Related Recipient Activity (WW)

  • Select one:

  • Develop a preventive health services program or preventive health services research study/studies.

  • Staff with at least two professional staff members to work full-time on WISEWOMAN or a plan for hiring such staff members.

  • Work with health care systems that can effectively deliver WISEWOMAN services and that target the population in need of these services.

  • Establish a cardiovascular disease prevention program as the primary focus, with culturally appropriate interventions addressing multiple risk factors that must include physical inactivity, poor nutrition, and tobacco use.

  • Implement screening, referral, and follow-up according to the recommendations of the National Cholesterol Education Program (NCEP).

  • Design culturally appropriate lifestyle interventions aimed at lowering blood pressure or cholesterol, improving physical activity or nutrition, or achieving smoking cessation in a similar target population.

  • Propose methods aimed at sustaining behavioral change.

  • Propose methods aimed at sustaining the program in future years.

  • Plan or conduct evaluation strategies to include reporting of suggested minimum data elements and cost information.

  • Formalize plans for Recipient Activities through development of program protocols or conduct program operations according to previously developed and approved program protocols.

  • Work collaboratively to develop methods that have the potential to be implemented in other WISEWOMAN programs.

Primary Priority Area* (HDSP)

  • Select one:

  • Control of high blood pressure

  • Control of high blood cholesterol

  • Increase knowledge of signs and symptoms and importance of calling 9-1-1

  • Improve emergency response

  • Improve quality care (prevent first and second events; control risk factors and diseases)

  • Eliminate Disparities

Secondary Priority Area (HDSP)

  • Select one:

  • Control of high blood pressure

  • Control of high blood cholesterol

  • Increase knowledge of signs and symptoms and importance of calling 9-1-1

  • Improve emergency response

  • Improve quality care (prevent first and second events; control risk factors and diseases)

  • Eliminate Disparities

Related HP2010 National Goal (HDSP)


  • Select one:

  • Prevention of Risk Factors

  • Detection and Treatment of Risk Factors

  • Early Identification and Treatment of Heart Attacks and Strokes

  • Prevention of Recurrent Cardiovascular Events

Direction of change* (HDSP)

  • Select one:

  • Increase

  • Decrease

Unit of Measurement* (HDSP)

  • Select one:

  • Number of

  • Percent of

  • Rate of

What will be measured? (HDSP)

  • Text

Baseline* (HDSP)

  • Numeric

  • Not required if “Baseline Unknown” is selected

Baseline Unknown (HDSP)

  • Select one:

  • Yes

  • No

Target * (HDSP)

  • Number

Evidence of measuring target* (HDSP)

  • Select one:

  • BRFS Cholesterol Awareness Module

  • BRFS Cardiovascular Disease Module

  • BRFS Heart Disease and Stroke Signs and Symptoms Module

  • BRFS Hypertension Awareness Module

  • Centers for Medicare and Medicaid Services (CMS)

  • Health Care Organization

  • Health Plan Employer Data and Information Set (HEDIS)

  • Hospital Discharge Data

  • U.S. Bureau of Census

  • Vital statistics

  • Youth Risk Behavior Surveillance (YRBS)

  • Other (Specify)

Other (specify) (HDSP)

  • Text

Measurement (WW)*

  • Select one

  • Increase the number of women to be screened each year for chronic disease risk factors and to receive risk reduction counseling based on the screening results.

  • Increase the percentage of new WISEWOMAN participants screened who return for the evaluation (first annual) screening visit within 10-14 months from baseline screening. This is required for purposes of program evaluation.

  • Increase the percentage of new women screened who attend at least one standardized lifestyle intervention session.

  • Increase the percentage of new women screened who have completed standardized lifestyle intervention sessions.

  • Decrease the percentage of failure to complete diagnostic/medical follow-up for women who have an alert screening value.

  • Increase the percentage of participants who adopt a healthier lifestyle during the year following baseline screening.

  • Reduce the percentage of expected cardiovascular disease events and deaths per 1,000 women, in 10 years.

Specify the measurement for the performance indicator selected above (WW)*

  • Baseline: Number

  • Target: Number

If baseline is unknown, explain how baseline will be defined: (HDSP)

  • Text

Which state plan objective does this objective relate to? (HDSP)

  • Text

Related RE-AIM Goal* (WW)

  • Select one:

  • To build a national WISEWOMAN program that provides every eligible NBCCEDP woman with an opportunity for WISEWOMAN services. (R-1)

  • To establish a WISEWOMAN program that reaches NBCCEDP women with the highest cardiovascular disease risk, including minority women in numbers that represent the proportion seen in NBCCEDP. (R-2)

  • To establish a WISEWOMAN program where at least 60% to 75% of the women screened receive the lifestyle intervention (LSI). (R-3)

  • To establish a WISEWOMAN program that improves lifestyle behavior. (E-1)

  • To establish a WISEWOMAN program that improves CVD risk scores. (E-2)

  • To ensure that WISEWOMAN is a cost effective program. (E-3)

  • To establish a WISEWOMAN program that is easy to adopt. (A-1)

  • To establish a WISEWOMAN program that can be delivered as intended (i.e. implemented with fidelity). (I-1)

  • To establish that the benefits of the WISEWOMAN program can be maintained over time at the individual level. (M-1)

  • To establish that the activities of the WISEWOMAN program can be sustained over time at the organizational level. (M-2)

Estimated Start Date*


  • Month and year

Estimated End Date*

  • Month and year

Describe revisions to this objective (required if target is updated, status is deferred or cancelled, start date is delayed, or end date is extended.):

  • Text


Intervention Supporting Objective

Question

Response Options

Objective Title*

  • Text

Objective Description*

  • Text

Status*

  • Select one:

  • Planned

  • In Process

  • Completed

  • Cancelled

  • Deferred

Setting

  • Select one:

  • Healthcare

  • Community

  • Worksite

  • Other (Specify)

Other (specify)

  • Text

Measurement (WW)*

  • Select one

  • Increase the number of women to be screened each year for chronic disease risk factors and to receive risk reduction counseling based on the screening results.

  • Increase the percentage of new WISEWOMAN participants screened who return for the evaluation (first annual) screening visit within 10-14 months from baseline screening. This is required for purposes of program evaluation.

  • Increase the percentage of new women screened who attend at least one standardized lifestyle intervention session.

  • Increase the percentage of new women screened who have completed standardized lifestyle intervention sessions.

  • Decrease the percentage of failure to complete diagnostic/medical follow-up for women who have an alert screening value.

  • Increase the percentage of participants who adopt a healthier lifestyle during the year following baseline screening.

  • Reduce the percentage of expected cardiovascular disease events and deaths per 1,000 women, in 10 years.

Specify the measurement for the performance indicator selected above (WW)*

  • Baseline: Number

  • Target: Number

Direction of change* (HDSP)

  • Select one:

  • Increase

  • Decrease

Unit of Measurement* (HDSP)

  • Select one:

  • Number of

  • Percent of

  • Rate of

What will be measured?* (HDSP)

  • Text

Baseline* (HDSP)

  • Numeric

  • Not required if “Baseline Unknown” is selected

Baseline Unknown

  • Select one:

  • Yes

  • No

Target * (HDSP)

  • Number

Evidence of measuring target* (HDSP)

  • Select one:

  • BRFS Cholesterol Awareness Module

  • BRFS Cardiovascular Disease Module

  • BRFS Heart Disease and Stroke Signs and Symptoms Module

  • BRFS Hypertension Awareness Module

  • Centers for Medicare and Medicaid Services (CMS)

  • Health Care Organization

  • Health Plan Employer Data and Information Set (HEDIS)

  • Hospital Discharge Data

  • U.S. Bureau of Census

  • Vital statistics

  • Youth Risk Behavior Surveillance (YRBS)

  • Other (Specify)

Other (specify) (HDSP)

  • Text

If baseline is unknown, explain how baseline will be defined:

  • Text

Objective Focus*

  • Select one:

  • General Population Based

  • WISEWOMAN Population Based (WW)

  • Priority Population Based (specify below)

    • Gender* (HDSP)

      • Select one:

        • Female

        • Male

        • Not Specific

    • Geography* (HDSP)

      • Select all that apply:

        • Rural / Low Density

        • Urban / High Density

        • Other (Specify)

        • Not Specified

    • Geography* (WW)

      • Select all that apply

        • City

        • County

        • District/Region

        • Entire State

        • Entire Territory

        • Frontier

        • Rural

        • Tribal Reservation/Service Area

        • Urban

        • Not Specific

    • Ethnicity*

      • Select all that apply:

        • Hispanic or Latino

        • Not Hispanic or Latino

        • Not Specific

    • Race*

      • Select up to 3:

        • American Indian or Alaska Native

        • Asian

        • African American or Black

        • Native Hawaiian or other Pacific Islander

        • White

        • Not Specified

    • SES* (HDSP)

      • Select one:

        • Low

        • Not Specified

Describe the steps taken to ensure the objective is culturally competent for the priority population identified. (HDSP)


Additional Population Comments (WW)

  • Text

Supplemental project (HDSP)

  • Select one:

  • None

  • Stroke Registry

  • Optional Funding

Summarize how resources have been leveraged for this objective*

  • Text

Estimated Start Date*


  • Month and year

Estimated End Date*

  • Month and year

Describe revisions to this objective (required if target is updated, status is deferred or cancelled, start date is delayed, or end date is extended.):

  • Text


Objective Progress

Question

Response Options

Date Progress Occurred*

  • Month and year

Describe Progress*

  • Text

Has the objective’s target been met?

  • Select one:

  • Yes

  • No

  • Currently Ongoing

Date objective’s target was met

  • Month and year

Actual Measurement

  • Direction of Change

  • Select one:

        • Increase

        • Decrease

  • Unit of Measurement

  • Select one

        • Number of

        • Percent of

        • Rate of

  • What was measured?: Text

  • Actual level: Number

Facilitating factors for success

  • Text

Describe any barriers and/or issues to meeting the objective and plans to overcome:

  • Text

Describe any additional benefits (unexpected outcomes) as a result of this objective:

  • Text


Activity

Question

Response Options

Activity Title*

  • Text

Activity Description*

  • Text

Estimated Start Date*

  • Month and year

Estimated End Date*

  • Month and year

Current Status*

  • Select one:

  • Planned

  • In Process

  • Completed

  • Cancelled

  • Deferred

Lead Personnel*

  • Select from list

Other personnel assigned to this activity

  • Select from list

Contractors assigned to this activity

  • Select from list

Partners assigned to this activity

  • Select from list

Describe Partner Involvement:

  • Text

Other (specify)

  • Text


Activity Progress (HDSP)

Question

Response Options

Date Progress Occurred*

  • Month and year

Describe Progress*

  • Text


Products

Question

Response Options

Title*

  • Text

Type*

  • Select one:

  • Audio

  • Book

  • Book Chapter

  • Booklet

  • Conference Paper

  • Conference Proceedings

  • Curriculum

  • Electronic Tool/Resource

  • Evaluation Plan

  • Fact Sheet

  • Featured Article

  • Journal Article

  • Manual

  • Newsletter

  • Policy Document

  • Poster/Billboard

  • Presentation

  • Press Kit

  • Report

  • Slideshow

  • Survey/Instruments

  • Video

  • Other (specify)

Other (specify)

  • Text

Product Description*

  • Text

Authors

  • Text

Product Focus*


  • Select one or more:

  • Assessment and inventory

  • Awareness approaches/strategies

  • Burden of Cardiovascular Disease

  • Cultural competence

  • Data Management

  • Disease/Risk Factors

  • Epidemiology

  • Environmental approaches/strategies

  • Evaluation

  • Health Communication

  • Lifestyle Intervention (Nutrition) (WW)

  • Lifestyle Intervention (Physical Activity) (WW)

  • Lifestyle Intervention (Tobacco) (WW)

  • Partnerships

  • Policy approaches/strategies

  • Population based strategies

  • Priority population strategies

  • Program planning

  • Recruitment (WW)

  • System approaches/strategies

  • Training & Technical Assistance

  • Other (specify)

Other (specify)

  • Text

Product Language*

  • Select all that apply

  • English

  • Spanish

  • Other(Specify)

Other (specify)

  • Text

Intended Audience*

  • Select one or more:

  • General Population (WW)

  • WISEWOMAN population (WW)

  • Priority Population (WW)

  • Community/local program

  • Decision/policy makers

  • Faith-based organization

  • General population

  • Healthcare organization

  • Healthcare provider

  • Lifestyle Intervention Delivery (WW)

  • Lifestyle Intervention Development (WW)

  • Local health department

  • Other state government entity

  • Priority population

  • Private sector business

  • State health department

  • Voluntary agency or professional organization

  • Other (specify)

Other (specify)

  • Text

Website Address

  • Text

Upload product

  • Text – file name

Date last revised

  • Date

Can this product be shared?

  • Select one:

  • Yes

  • No



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