Form 14 KI Protocol

SSA Attachment 14

HEALTHY COMMUNITIES STUDY

Healthy Communities Study

Key Informant Interview Protocol and Document Abstraction Form

This document provides an overview of the protocol for the community key informants. Protocol materials include the recruitment script, consent form, the verbal consent script,the post-baseline new/replacement key informant verbal consent script and the interview instrument to be administered to the community key informants. These data collection materials will be used at the time of the in-person visit at all 279 communities and the follow-up in-person visit three years later at the 40 RIPA communities by the Battelle community liaison. The remote follow-up, administered by either telephone or the internet with key informants in the first 200 Wave 2 communities, will include specific questions from the interview as denoted in the attached instruments.

Once a potential key informant is successfully screened, the Battelle research staff will continue the call with the individual to preview the content of the in-person interview and request documentation on community programs/policies using the recruitment script. The in-person interview time will also be scheduled. If it is not possible to conduct an in-person visit, a telephone interview will be scheduled instead. The key informant will also be sent an informational letter (Attachment 11), along with a study brochure (Attachment 12) tailored to community leaders, and confirming the appointment for the structured interview.

Prior to the interview, if any documents provided by the key informant are received, the Battelle community liaison will pre-enter information about the program into the information management system, so that this information is accessible during the interview.

At the time of the interview, the Battelle community liaison will first explain the study, review the consent document, and then answer any questions the key informant may have. If the interview is in person, the key informant will be asked to sign the informed consent form prior to the initiation of the interview. When the key informant is unable to participate in an in-person interview and completes a telephone interview instead, a verbal consent script will be read before the interview begins. A separate verbal consent script will also be used if a key informant is replaced during the study (e.g., a program replaces its director or a school principal changes) and this new key informant is contacted for any study remaining activities.

The standardized key informant interview instrument gathers characteristics for each program and policy operating in the selected communities, such as the target population, target focus area, funding, reach, and (where available) the outcomes examined. Key informants will answer a similar set of interview questions for each specific local program and/or policy identified during the interviews, and data will be combined from different key informant interviews for the same program or policy. At the end of the interview, the Battelle community liaison will request consent for follow-up interviews and give the key informant the incentive gift.

Community key informants in the first 200 Wave 2 communities will undergo a remote follow-up interview either over the telephone or the web to document changes in programs or policies that have occurred since the baseline assessment. For the 40 RIPA communities, a local community documenter -- a key informant in that community that will be offered a yearly stipend – will document how programs and policies evolve over a three-year follow-up period in that community. A second in-person visit to the 40 RIPA communities will be conducted at the end of the three-year follow-up period to repeat the baseline interview.

HEALTHY COMMUNITIES STUDY

COMMUNITY KEY INFORMANT RECRUITMENT SCRIPT

Public reporting burden of this collection of information is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining 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 S. Sonia Arteaga, Ph.D., project officer at [email protected]

I would like to take a few moments to tell you about what will take place during the interview. The primary goal is to assemble and understand in specific detail programs, policies, and changes to the physical environment that are in place in each selected community to promote physical activity, healthy eating, and healthy weight. To that end, we will ask you questions like:

• What specific programs were implemented to promote physical activity? What about programs to promote healthy nutrition?

• What specific policies were implemented to promote physical activity? What about policies to promote healthy nutrition?

• What specific changes to the physical environment (such as a new bike path or walking trail) were made to promote physical activity? What about changes in the physical environment to promote healthy nutrition?

For each of the community programs/policies that you tell me about, we will ask you for more detailed information such as the dates that the activity was implemented and the number of people served. If you have some time beforehand, you might start assembling this kind of information. In addition, after this call, I will be sending you a letter reminding you of our interview time and providing specific examples of the kinds of questions that will be asked.

In addition to these interviews, we are collecting documents that may contain information about community programs/ policies to promote healthy weight, healthy eating, and engagement in physical activity.

The types of documents that we would like to collect include: a) Annual Program Reports for your organization or coalitions or partnerships working on this issue; b) Reports provided to funders; and c) Any other available reports or documents that describe community programs/policies brought about to promote physical activity or healthy eating for children and youth.

Would you be able to access any of these documents, or other documents that we might find informative?

If yes, provide information about how these items can be emailed or shipped.

If no, tell them we will try to collect them during the in-person interview.

Finally, before we conclude, I wanted to tell you that we are trying to get as complete a picture as possible of the program, policies, and changes to the physical environment to promote physical activity, healthy eating, and healthy weight that have been implemented in your community. Who else would you recommend that we interview?

[Possible probes: Are there other people within your organization that could be interviewed with you at the same time? Can you think of people across the community that should be interviewed? You might consider those who work at [list all of the sectors, except the one in which the person works in? Are there other people who may know about community efforts back to 2000?]

[Prompt for contact information when possible]

Great, this is really helpful information. This is all that I was hoping to review today. Do you have any questions for me? [Answer as best as possible]

Thank you for your time today. I really appreciate it, and I look forward to speaking to you on (insert date of interview) at (insert time of interview). You have been very helpful. Have a good day.

HEALTHY COMMUNITIES STUDY

MASTER KEY INFORMANT/ COMMUNITY PROGRAM DIRECTOR CONSENT FORM¹

PURPOSE

The purpose of the Healthy Communities Study is to see what programs and policies in communities across the United States help children lead healthy lives and to examine how these programs have changed over time. This study is being conducted by a research company, Battelle Centers for Public Health Research and Evaluation. It is funded by the National Institutes of Health (NIH).

PROCEDURES – NON-RIPA COMMUNITY RESPONDENTS

If you agree to be in this study, a trained member of our research staff will meet with you in person one time to conduct an interview. The interview will be about your community in general as well as your knowledge of and perceptions about various community level programs designed to impact healthy behaviors in children. The interview should take about one hour. We will also collect from you any documents you can provide to help us understand how the programs have evolved and the impact they have had on your community.

[One year/Two years] from now, we will contact you again and ask you to answer approximately 50 minutes worth of questions through a web or telephone survey. The questions will be similar to those you answered during the in-person visit.

PROCEDURES – RIPA COMMUNITY RESPONDENTS

If you agree to be in this study, a trained member of our research staff will meet with you in person to conduct an interview two times, now and again three years from now. Each interview will be about your community in general as well as your knowledge of and perceptions about various community level programs designed to impact healthy behaviors in children. Each interview should take about one hour. We will also collect from you any documents you can provide to help us understand how the programs have evolved and the impact they have had on your community.

Following this initial interview, and up until your next in-person structured interview three years from now, you will also be contacted approximately every three months by a trained member of our research staff to conduct a very brief survey with you in order to assess any program changes during the previous quarter. The staff member may also request to review any documents you may have related to recent program changes.

Two years from now, we will contact you again and ask you to answer approximately 50 minutes’ worth of questions through a web or telephone survey. The questions will be similar to those you answered during the in-person visit.

HOW YOU WERE SELECTED

You were selected to be in the study because you work in one of the 279 communities we are studying and you were identified as a community leader working on this issue. Over 3,500 such community members will eventually participate in this study.

CONFIDENTIALITY

The study team will do everything they can to make sure your information stays private and secure. All study staff are required to complete training on keeping your information safe. Study laptops and equipment are password protected. They also have programs to protect your information. Your information will be stored in a locked building with access limited to authorized study team members only. Study data forms will only have your study identification number on it.

The only reason we would have to break confidentiality, as required by law, is if the Institutional Review Board (IRB), the body that oversees the protection of study participants, needs to review records. Final study results will be published on groups only. No individual information will be included. No individual in this study will be able to be identified.

RISKS/DISCOMFORTS

There are few known risks to participation in this study. We will not ask you personal questions. Because the study is voluntary, you do not need to answer any question you do not feel comfortable answering. There is a small risk of loss of confidentiality. Every effort will be made to keep your information safe and secure.

BENEFITS

The results of this study could help improve existing and future programs for children across the United States. This study has no known direct or individual benefits for participation. However, it is important for you to participate because it will help researchers understand what programs in the community help children stay healthy

COSTS AND COMPENSATION

There is no cost for being in this study. In appreciation of your participation, after [the/each] in-person visit you will receive a gift worth $10.

If you complete the follow-up web or telephone questions in a few years, we will mail you another gift worth $10. As an additional thank you for your participation in this study, at the end of the study, you will get a summary report of the study results for all communities.

DATA SHARING

Data collected during the course of this study related to the community program with which you are affiliated may be of benefit and value to those operating other federally funded programs or initiatives within your community (for example, programs under the White House’s Let’s Move! Initiative) and may be shared with researchers investigating other community-level factors associated with reducing levels of childhood obesity. Data will only be shared with other entities that are compliant with the Federal Information Security Management Act of 2002 (FISMA), meaning that they have documented protocols for keeping information and information systems secure. As stated in the Confidentiality Section, no individual information will be shared and no individual will be identifiable.

VOLUNTARY

Participation in this study is voluntary. You may ask questions at any time. You may refuse to answer any question. You may also drop out at any time without penalty.

CONTACT INFORMATION

For questions about your rights as a study participant, contact:

Battelle Institutional Review Board

1-877-810-9530

For questions or concerns about the study:

Dr. Howard Fishbein

Battelle Centers for Public Health Research and Evaluation

703-248-1647

I have read this consent form and the study staff have answered my questions.

I, _____________________________­­­­­­­­­­­­­­­­___________________, (PRINTED FULL NAME) agree to participate in the “HEALTHY COMMUNITIES STUDY.”

_________________________________________________________ _________________________

^{Signature Date}

________________________________

^{Witness Signature}

HEALTHY COMMUNITIES STUDY

MASTER KEY INFORMANT/ COMMUNITY PROGRAM DIRECTOR VERBAL CONSENT SCRIPT²

PURPOSE

The purpose of the Healthy Communities Study is to see what programs and policies in communities across the United States help children lead healthy lives and to examine how these programs have changed over time. This study is being conducted by a research company, Battelle Centers for Public Health Research and Evaluation. It is funded by the National Institutes of Health (NIH).

PROCEDURES – NON-RIPA COMMUNITY RESPONDENTS

If you agree to be in this study, a trained member of our research staff will conduct a structured interview with you over the phone. The interview will be about your community in general as well as your knowledge of and perceptions about various community level programs designed to impact healthy behaviors in children. The interview should take about one hour. We will also request from you any documents you can provide to help us understand how the programs have evolved and the impact they have had on your community.

[One year/Two years] from now, we will contact you again and ask you to answer approximately 50 minutes worth of questions through a web or telephone survey. The questions will be similar to those you answered during this interview.

PROCEDURES – RIPA COMMUNITY RESPONDENTS

If you agree to be in this study, a trained member of our research staff will conduct a structured interview with you over the phone two times; now and again three years from now. Each interview will be about your community in general as well as your knowledge of and perceptions about various community level programs designed to impact healthy behaviors in children. Each interview should take about one hour. We will also request from you any documents you can provide to help us understand how the programs have evolved and the impact they have had on your community.

Following this initial interview, and up until your next structured interview three years from now, you will also be contacted approximately every three months by a trained documenter to conduct a very brief survey with you in order to assess any program changes during the previous quarter. The documenter may also request to review any documents you may have related to recent program changes.

Two years from now, we will contact you again and ask you to answer approximately 50 minutes worth of questions through a web or telephone survey. The questions will be similar to those you answered during this interview.

HOW YOU WERE SELECTED

You were selected to be in the study because you work in one of the 279 communities we are studying and you were identified as a community leader working on this issue. Over 3,500 such community members will eventually participate in this study.

CONFIDENTIALITY

The study team will do everything they can to make sure your information stays private and secure. All study staff are required to complete training on keeping your information safe. Study laptops and equipment are password protected. They also have programs to protect your information. Your information will be stored in a locked building with access limited to authorized study team members only. Study data forms will only have your study identification number on it.

The only reason we would have to break confidentiality, as required by law, is if the Institutional Review Board (IRB), the body that oversees the protection of study participants, needs to review records. Final study results will be published on groups only. No individual information will be included. No individual in this study will be able to be identified.

RISKS/DISCOMFORTS

There are few known risks to participation in this study. We will not ask you personal questions. Because the study is voluntary, you do not need to answer any question you do not feel comfortable answering. There is a small risk of loss of confidentiality. Every effort will be made to keep your information safe and secure.

BENEFITS

The results of this study could help improve existing and future programs for children across the United States. This study has no known direct or individual benefits for participation. However, it is important for you to participate because it will help researchers understand what programs in the community help children stay healthy.

COSTS AND COMPENSATION

There is no cost for being in this study. In appreciation of your participation, after [the/each] interview you will receive a gift worth $10.

If you complete the follow-up web or telephone questions in a few years, we will mail you another gift worth $10. As an additional thank you for your participation in this study, at the end of the study, you will get a summary report of the study results for all communities.

DATA SHARING

Data collected during the course of this study related to the community program with which you are affiliated may be of benefit and value to those operating other federally funded programs or initiatives within your community (for example, programs under the White House’s Let’s Move! Initiative) and may be shared with researchers investigating other community-level factors associated with reducing levels of childhood obesity. Data will only be shared with other entities that are compliant with the Federal Information Security Management Act of 2002 (FISMA), meaning that they have documented protocols for keeping information and information systems secure. As stated in the Confidentiality Section, no individual information will be shared and no individual will be identifiable.

VOLUNTARY

Participation in this study is voluntary. You may ask questions at any time. You may refuse to answer any question. You may also drop out at any time without penalty.

CONTACT INFORMATION

If you have any questions about your rights as a study participant, please contact the Battelle Institutional Review Board at 1-877-810-9530.

If you have any questions or concerns about the study, please contact the Study PI Dr. Howard Fishbein of Battelle Centers for Public Health Research and Evaluation at 1-703-248-1647.

Do you have any questions before we begin?

HEALTHY COMMUNITIES STUDY

MASTER KEY INFORMANT/ COMMUNITY PROGRAM DIRECTOR

POST BASELINE NEW/REPLACEMENT KEY INFORMANT

VERBAL CONSENT SCRIPT³

PURPOSE

The purpose of the Healthy Communities Study is to see what programs and policies in communities across the United States help children lead healthy lives and to examine how these programs have changed over time. This study is being conducted by a research company, Battelle Centers for Public Health Research and Evaluation. It is funded by the National Institutes of Health (NIH).

PROCEDURES – NON-RIPA COMMUNITY RESPONDENTS

If you agree to be in this study, you will be asked to answer approximately 50 minutes’ worth of questions through a web or telephone survey. The interview will be about your community in general as well as your knowledge of and perceptions about various community level programs designed to impact healthy behaviors in children.

PROCEDURES – RIPA COMMUNITY RESPONDENTS

If you agree to be in this study, depending on when you join the study, you may be asked to answer approximately 50 minutes’ worth of questions through a web or telephone survey. The interview will be about your community in general as well as your knowledge of and perceptions about various community level programs designed to impact healthy behaviors in children.

You may also be contacted approximately every three months by a trained member of our research staff to conduct a very brief survey with you in order to assess any program changes during the previous quarter. The staff member may also request to review any documents you may have related to recent program changes.

You will also be contacted by a trained member of our research staff who will meet with you in person in the final year of our study to conduct a structured interview one time.. The interview will be about your community in general as well as your knowledge of and perceptions about various community level programs designed to impact healthy behaviors in children. The interview should take about one hour. We will also collect from you any documents you can provide to help us understand how the programs have evolved and the impact they have had on your community.

HOW YOU WERE SELECTED

You were selected to be in the study because you work in one of the 279 communities we are studying and you were identified as a community leader working on this issue. Over 3,500 such community members will eventually participate in this study.

CONFIDENTIALITY

The study team will do everything they can to make sure your information stays private and secure. All study staff are required to complete training on keeping your information safe. Study laptops and equipment are password protected. They also have programs to protect your information. Your information will be stored in a locked building with access limited to authorized study team members only. Study data forms will only have your study identification number on it.

The only reason we would have to break confidentiality, as required by law, is if the Institutional Review Board (IRB), the body that oversees the protection of study participants, needs to review records. Final study results will be published on groups only. No individual information will be included. No individual in this study will be able to be identified.

RISKS/DISCOMFORTS

There are few known risks to participation in this study. We will not ask you personal questions. Because the study is voluntary, you do not need to answer any question you do not feel comfortable answering. There is a small risk of loss of confidentiality. Every effort will be made to keep your information safe and secure.

BENEFITS

The results of this study could help improve existing and future programs for children across the United States. This study has no known direct or individual benefits for participation. However, it is important for you to participate because it will help researchers understand what programs in the community help children stay healthy.

COSTS AND COMPENSATION

There is no cost for being in this study. If you complete the follow-up web or telephone questions in a few years, we will mail you a gift worth $10. In appreciation of your participation, after the final in-person interview you will receive a gift worth $10. As an additional thank you for your participation in this study, at the end of the study, you will get a summary report of the study results for all communities.

DATA SHARING

Data collected during the course of this study related to the community program with which you are affiliated may be of benefit and value to those operating other federally funded programs or initiatives within your community (for example, programs under the White House’s Let’s Move! Initiative) and may be shared with researchers investigating other community-level factors associated with reducing levels of childhood obesity. Data will only be shared with other entities that are compliant with the Federal Information Security Management Act of 2002 (FISMA), meaning that they have documented protocols for keeping information and information systems secure. As stated in the Confidentiality Section, no individual information will be shared and no individual will be identifiable.

VOLUNTARY

Participation in this study is voluntary. You may ask questions at any time. You may refuse to answer any question. You may also drop out at any time without penalty.

CONTACT INFORMATION

If you have any questions about your rights as a study participant, please contact the Battelle Institutional Review Board at 1-877-810-9530.

If you have any questions or concerns about the study, please contact the Study PI Dr. Howard Fishbein of Battelle Centers for Public Health Research and Evaluation at 1-703-248-1647.

Thank you for agreeing to help us with this important study.

HEALTHY COMMUNITIES STUDY

KEY INFORMANT INTERVIEW

This interview is comprised of the following sections:

SECTION A: Key Informant Level Data

SECTION B: Community/Organization Level Data

SECTION C: Program/Policy Level Data (Interview and Document Abstraction/Review Form)

SECTION D: Job Specific Addendum Data (Baseline Only)

* Question to also be asked or documented during the Follow-up (In-Person, Telephone, or Website) Interview: Responses to be based on changes and updates since the previous interview (section introductions and question wording will be amended accordingly).

SECTION A ENTER INFORMATION; DO NOT ASK RESPONDENT.
A1. *	DATE OF INTERVIEW.		/ / MONTH DAY YEAR
A2. *	TIME INTERVIEW BEGAN.		: AM / PM
A2a. *	LIAISON ID.
A3. *	KEY INFORMANT STUDY ID.
A4.	KEY INFORMANT GENDER.		MALE 1 FEMALE 2
Good (morning/afternoon), thank you very much for taking the time to speak with me today. As part of our Healthy Communities Study, funded by the National Institutes of Health (NIH), we will be talking about efforts in (name the community) to promote physical activity, healthy nutrition, and healthy weight among children and youth. The purpose of our study is to identify characteristics of community programs and policies that may have an impact on childhood obesity rates. Because of the work you do within your community, we feel you can provide valuable information to help us address this issue. Before we get started, I would like to remind you that this is a research study and as such you are a research participant. I will now review our consent form. IF A FACE-TO-FACE INTERVIEW, HAND RESPONDENT A COPY OF THE CONSENT FORM. ONCE THE FORM IS REVIEWED AND ALL QUESTIONS ARE ANSWERED, HAVE THE RESPONDENT SIGN THE CONSENT FORM AND RETURN. LEAVE A COPY WITH THEM FOR THEIR RECORDS. OTHERWISE, DOCUMENT VERBAL CONSENT. Thank you. I would now like to ask you to verify your name and contact information in case we have additional questions or would like to clarify any information we discuss today.
A5. *	What is your full name?		__________________________
A6. *	What is your mailing address? ADDRESS 1 – Business/Organization Name: ADDRESS 2 – Number / Street Name: ADDRESS 3 – City, State ZIP:		__________________________ __________________________ __________________________
A7. *	What is your preferred phone number?		__________________________
A8. *	What is your preferred e-mail address?		__________________________
I now have some basic background and demographic information to ask you. These questions are simple and straightforward and as with all other data we will be collecting today are strictly confidential.
A9. *	What is your job title? READ ANSWERS.		Parks and Recreation Administrator/ Staff Member 1 Urban Planner 2 Local Health Department Administrator/Staff Member 3 Chair of an active Community Health Coalition 4 School Principal 5 School Food Service Administrator 6 School Health Coordinator 7 School Physical Activity Coordinator 8 Healthcare Provider 9 Non-Profit Staff/Administrator 10 Human Service Provider 11 Youth-Serving Organization Staff/Administrator 12 Other 13 REFUSED 97 DON’T KNOW 98
	SPECIFY:		_______________________________
IF Q.A9 = ANY RESPONSE 1 - 8, ASK RELATED QUESTIONS IN SECTIONS B and D. ELSE, FOLLOWING COMPLETION OF SECTION C, END THE INTERVIEW.
A10. *	What company/organization/department do you work with?		_______________________________
A11. *	What sector or part of the community do you work within? READ ANSWERS. USE RESPONSE CHOICES CARD. SPECIFY:		Education 1 Health Organization/Coalition 2 Government 3 Non-profit/Community organization/Service agency 4 Other 5 REFUSED 7 DON’T KNOW 8 _______________________________
IF Q.A11 = 1, ASK A11a. ELSE SKIP TO Q.A12
	A11a. What type of school do you work with? READ ANSWERS. USE RESPONSE CHOICES CARD. *		Elementary School 1 Middle/Jr. High School 2 High School 3 College Level 4 refused 7 don’t know 8
A12. *	Do you live in this community?		YES 1 NO 2 refused 7 don’t know 8
IF Q. A12 = 1, ASK A12a. ELSE SKIP TO Q.13
	A12a. How long have you lived in the community? *		NUMBER YEARS NUMBER MONTHS refused 7 don’t know 8
A13. *	How long have you been involved with community issues related to nutrition, physical activity, and healthy weight of children and youth?		NUMBER YEARS NUMBER MONTHS refused 7 don’t know 8
A14.	What is the highest grade or level of education you have completed or the highest degree you have received?		never attended/ kindergarten only 1 1st grade 2 2nd grade 3 3rd grade 4 4th grade 5 5th grade 6 6th grade 7 7th grade 8 8th grade 9 9th grade 10 10th grade 11 11th grade 12 12th grade 13 12th grade, NO DIPLOMA 14 high school graduate 15 ged or equivalent 16 some college, no degree 17 associate degree: occupational, technical, or vocational program 18 associate degree: academic program 19 bachelor’s degree (ba, ab, bs, bba) 20 master’s Degree (ma, ms, meng, med, mba) 21 professional school degree (MD, DDS, DVM, JD) 22 doctoral degree (PHD, EDD) 23 refused 7 don’t know 8
A15.	Do you consider yourself Hispanic/Latin(o/a)?		YES 1 NO 2 refused 7 don’t know 8
IF Q.A15 = 1, ASK A15a. ELSE SKIP TO Q.16
	A15a. Which of the following represent your Hispanic origin or ancestry? READ ANSWERS. CODE ALL THAT APPLY.		Puerto Rican 1 Dominican (Republic) 2 Mexican/Mexican American 3 Cuban/Cuban American 4 Central/South American 5 Other Latin American 6 Other Hispanic Or Latino 7 refused 97 don’t know 98
A16.	What race do you consider yourself to be? CODE ALL THAT APPLY. SPECIFY:		WHITE 1 BLACK/ AFRICAN AMERICAN 2 AMERICAN INDIAN 3 ALASKAN NATIVE 4 NATIVE HAWAIIAN 5 GUAMANIAN 6 SAMOAN 7 OTHER PACIFIC ISLANDER (SPECIFY) 8 ASIAN INDIAN 9 CHINESE 10 FILIPINO 11 JAPANESE 12 KOREAN 13 VIETNAMESE 14 OTHER ASIAN (SPECIFY) 15 AMERICAN 16 SOME OTHER RACE (SPECIFY) 17 REFUSED 97 DON’T KNOW 98 __________________________________
A17.	What languages do you speak? CODE ALL THAT APPLY.		ENGLISH 1 SPANISH 2 OTHER 3 REFUSED 7 DON’T KNOW 8
CONTINUE TO SECTION B: KEY INFORMANT ORGANIZATION INFORMATION.

This form represents the one module that should be completed for each individual ORGANIZATION. With each new key informant interview, this one module should be added to. * Question to also be asked or documented during the Follow-up (In-Person, Telephone, or Website) Interview: Responses to be based on changes and updates since the previous interview (section introductions and question wording will be amended accordingly). SECTION B
	*ORGANIZATION STUDY ID
I would now like for us to talk broadly about your community’s efforts to promote physical activity, healthy nutrition, and /or healthy weight, and then more specifically about your organization’s efforts through particular program and policy development and implementation.
B1. *	To what extent has your community been active in promoting physical activity, healthy nutrition, and/or healthy weight among children or youth? Think broadly as we want to collect as much information as possible.			_____________________________
	[POSSIBLE PROBES: Please describe how people have been working together to promote physical activity, healthy eating, or healthy weight among children and youth. What is happening? How has it been going?; What parts of the community have been active in encouraging this – schools, health department, government, United Way agencies, other organizations or community coalitions/partnerships?]
Now, I would like to talk more specifically about what your organization (insert organization name) has done to promote physical activity, healthy nutrition and/or healthy weight among children and youth. We are attempting to document what programs or policies have been implemented in the community since 2000. FOR EACH PROGRAM/POLICY INDICATED BELOW (IN QUESTIONS Q.B2 – Q.B7), OPEN A NEW PROGRAM/POLICY LEVEL MODULE (SECTION D) AND COMPLETE.
For PHYSICAL ACTIVITY, we are interested in your organization’s efforts to make it easier or more likely for children and youth to be more physically active.
B2. *	What specific programs were implemented within or by your organization to promote physical activity? [In the past 5 years? Since 2000?] ALLOW PARTICIPANT TO LIST THE DIFFERENT ORGANIZATION LEVEL PROGRAMS; ENTER ONE PROGRAM NAME AT A TIME – FOR EACH ADDITIONAL PROGRAM, ADD A ROW.			____________________________ ADD A ROW FOR EACH NEW PROGRAM
B3. *	What specific policies were implemented within or by your organization to promote physical activity? [In the past 5 years? Since 2000?] ALLOW PARTICIPANT TO LIST THE DIFFERENT ORGANIZATION LEVEL POLICIES; ENTER ONE POLICY NAME AT A TIME – FOR EACH ADDITIONAL POLICY, ADD A ROW.			____________________________ ADD A ROW FOR EACH NEW P OLICY
B4. *	What specific changes to the physical environment were made within or by your organization to promote physical activity? [In the past 5 years? Since 2000?] ALLOW PARTICIPANT TO LIST THE DIFFERENT ORGANIZATION LEVEL ENVIRONMENTAL CHANGE; ENTER ONE CHANGE AT A TIME – FOR EACH ADDITIONAL CHANGE, ADD A ROW.			____________________________ ADD A ROW FOR EACH NEW E NVIRONMENTAL CHANGE
THE FOLLOWING QUESTIONS, (Q.B5 – Q.B8), WHICH ARE RELATED TO PHYSICAL ACTIVITY EFFORTS WITHIN THE COMMUNITY, ARE TO BE ASKED OF A KEY INFORMANT WHO IS EITHER: PARKS AND RECREATION ADMINISTRATOR/STAFF MEMBER (Q.A9 = 1) OR URBAN PLANNER (Q.A9 = 2).
B5.	Has your organization planned and/or implemented programs or events (not yet mentioned) to specifically promote physical activity at your parks or within your community? ALLOW PARTICIPANT TO LIST THE DIFFERENT ORGANIZATION LEVEL PROGRAMS/EVENTS; ENTER ONE AT A TIME – FOR EACH ADDITIONAL POLICY, ADD A ROW.			____________________________ ADD A ROW FOR EACH NEW PROGRAM/EVENT
B6.	Has your organization partnered with an outside organization (e.g., health department, non-profit agency, health care organization) specifically to promote physical activity at your parks or within your community (not yet mentioned)? ALLOW PARTICIPANT TO LIST THE DIFFERENT ACTIVITIES; ENTER ONE AT A TIME – FOR EACH ADDITIONAL ACTIVITY, ADD A ROW.			____________________________ ADD A ROW FOR EACH NEW ACTIVITY
B7.	Has your organization planned and/or implemented improvements to physical features at your parks or within the community, such as additional park lighting, pedestrian/biking routes, new fitness trails and/or parks? ALLOW PARTICIPANT TO LIST THE DIFFERENT IMPROVEMENTS; ENTER ONE AT A TIME – FOR EACH ADDITIONAL IMPROVEMENT, ADD A ROW.			____________________________ ADD A ROW FOR EACH NEW IMPROVEMENT
B8.	Has your organization partnered with an outside organization (e.g., health department, non-profit agency, health care organization) to plan and/or implement improvements to physical features at your parks or within the community, such as additional park lighting, pedestrian/biking routes, new fitness trails and/or parks? ALLOW PARTICIPANT TO LIST THE DIFFERENT IMPROVEMENTS; ENTER ONE AT A TIME – FOR EACH ADDITIONAL IMPROVEMENT, ADD A ROW.			____________________________ ADD A ROW FOR EACH NEW IMPROVEMENT
For NUTRITION, we are interested in your organization’s efforts to make it easier or more likely for children and youth to eat healthier foods.
B9. *		What specific programs were implemented within or by your organization to promote healthy nutrition? [In the past 5 years? Since 2000?] ALLOW PARTICIPANT TO LIST THE DIFFERENT ORGANIZATION LEVEL PROGRAMS; ENTER ONE PROGRAM NAME AT A TIME – FOR EACH ADDITIONAL PROGRAM, ADD A ROW.		____________________________ ADD A ROW FOR EACH NEW PROGRAM
B10. *		What specific policies were implemented within or by your organization to promote healthy nutrition? [In the past 5 years? Since 2000?] ALLOW PARTICIPANT TO LIST THE DIFFERENT ORGANIZATION LEVEL POLICIES; ENTER ONE POLICY NAME AT A TIME – FOR EACH ADDITIONAL POLICY, ADD A ROW.		____________________________ ADD A ROW FOR EACH NEW P OLICY
B11. *		What specific changes to the physical environment were made within or by your organization to promote healthy nutrition? [In the past 5 years? Since 2000?] ALLOW PARTICIPANT TO LIST THE DIFFERENT ORGANIZATION LEVEL ENVIRONMENTAL CHANGE; ENTER ONE CHANGE AT A TIME – FOR EACH ADDITIONAL CHANGE, ADD A ROW.		____________________________ ADD A ROW FOR EACH NEW E NVIRONMENTAL CHANGE
THE FOLLOWING QUESTIONS (B12 – B14), WHICH ARE RELATED TO NUTRITION EFFORTS WITHIN THE COMMUNITY, ARE TO BE ASKED OF A KEY INFORMANT WHO IS EITHER: LOCAL HEALTH DEPARTMENT ADMINISTRATOR/STAFF MEMBER (Q.A9 = 3) OR CHAIR OF AN ACTIVE COMMUNITY HEALTH COALITION (Q.A9 = 4)
B12.		Have there been any other policies or programs implemented (not yet mentioned) to improve the foods, food marketing, or nutrition education offered at any type of restaurant (including fast food) or to establish new restaurants with healthy options in this community? ALLOW PARTICIPANT TO LIST THE DIFFERENT EFFORTS; ENTER ONE EFFORT AT A TIME – FOR EACH ADDITIONAL EFFORT, ADD A ROW.		____________________________ ADD A ROW FOR EACH NEW PROGRAM/POLICY
B13.		Have there been any other policies or programs implemented (not yet mentioned) to improve the foods, food marketing, or nutrition education available at any type of stores (including supermarkets, convenience stores, etc.) or to establish new stores with healthy options in the community? ALLOW PARTICIPANT TO LIST THE DIFFERENT EFFORTS; ENTER ONE EFFORT AT A TIME – FOR EACH ADDITIONAL EFFORT, ADD A ROW.		____________________________ ADD A ROW FOR EACH NEW PROGRAM/POLICY
B14.		Are there additional people we should talk to about store and restaurant-related efforts?		YES 1 NO 2 REFUSED 7 DON’T KNOW 8
IF Q.B14 = 1, COMPLETE Q.B14a FOR EACH CONTACT. ELSE SKIP TO Q.B15.
		B14a. Please provide the name and contact information for the individuals we should contact.		_______________________________
THE FOLLOWING QUESTIONS (B15 – B16), WHICH ARE RELATED TO NUTRITION EFFORTS WITHIN THE COMMUNITY, ARE TO BE ASKED OF A KEY INFORMANT WHO IS EITHER: SCHOOL PRINCIPAL (Q.A9 = 5) OR SCHOOL FOOD SERVICE ADMINISTRATOR (Q.A9 = 6) OR SCHOOL HEALTH COORDINATOR (Q.A9 = 7).
B15.		Have there been any other programs/policies implemented (not yet mentioned) to improve any of the following at your school/the schools in your community: School meals; Meal facilities and equipment (kitchen, dining, and serving facilities); Competitive foods (foods sold in vending machines, snack bars, stores, etc.); Foods at classroom parties and school events; Food used as reward; Food and beverage marketing; Nutrition education or weight management activities; Nutrition promotion events and activities; Staff wellness activities and environments? ALLOW PARTICIPANT TO LIST THE DIFFERENT EFFORTS; ENTER ONE EFFORT AT A TIME – FOR EACH ADDITIONAL EFFORT, ADD A ROW.		____________________________ ADD A ROW FOR EACH NEW P ROGRAM/POLICY
		B15a. For each new program/policy, please briefly describe who, did what, with whom, and with what intended result.		_____________________________
B16.		Are there additional people we should talk in order to cover all these aspects of schools foods and nutrition?		YES 1 NO 2 REFUSED 7 DON’T KNOW 8
IF Q.B16 = 1, COMPLETE Q.B16a FOR EACH CONTACT. ELSE SKIP TO Q.B17.
		B16a. Please provide the name and contact information for the individuals we should contact.		_______________________________

Now, I would like to talk more specifically about what other community organizations have done to promote physical activity, healthy nutrition and/or healthy weight among children and youth. Since 2000, what programs or policies have been implemented by others outside your organization to promote physical activity, healthy eating, or healthy weight among children and youth?

FOR EACH PROGRAM/POLICY INDICATED BELOW (IN QUESTIONS Q.B17 – Q.B22), OPEN A NEW PROGRAM/POLICY LEVEL MODULE (SECTION D) AND COMPLETE.

For Physical Activity, we are interested in community efforts to make it easier or more likely for children and youth to be more physically active.

B17.

*

What specific programs were implemented to promote physical activity? [In the past 5 years? Since 2000?]

ALLOW PARTICIPANT TO LIST THE DIFFERENT ORGANIZATION LEVEL PROGRAMS; ENTER ONE PROGRAM NAME AT A TIME – FOR EACH ADDITIONAL PROGRAM, ADD A ROW.

____________________________

ADD A ROW FOR EACH NEW PROGRAM

B18.

*

What specific policies were implemented to promote physical activity? [In the past 5 years? Since 2000?]

ALLOW PARTICIPANT TO LIST THE DIFFERENT ORGANIZATION LEVEL POLICIES; ENTER ONE POLICY NAME AT A TIME – FOR EACH ADDITIONAL POLICY, ADD A ROW.

____________________________

ADD A ROW FOR EACH NEW P OLICY

B19.

*

What specific changes to the physical environment were made to promote physical activity? [In the past 5 years? Since 2000?]

ALLOW PARTICIPANT TO LIST THE DIFFERENT ORGANIZATION LEVEL ENVIRONMENTAL CHANGE; ENTER ONE CHANGE AT A TIME – FOR EACH ADDITIONAL CHANGE, ADD A ROW.

____________________________

ADD A ROW FOR EACH NEW E NVIRONMENTAL CHANGE

For Nutrition, we are interested in community efforts to make it easier or more likely for children and youth to eat healthier foods.

B20.

*

What specific programs were implemented to promote healthy nutrition? [In the past 5 years? Since 2000?]

ALLOW PARTICIPANT TO LIST THE DIFFERENT ORGANIZATION LEVEL PROGRAMS; ENTER ONE PROGRAM NAME AT A TIME – FOR EACH ADDITIONAL PROGRAM, ADD A ROW.

____________________________

ADD A ROW FOR EACH NEW PROGRAM

B21.

*

What specific policies were implemented to promote healthy nutrition? [In the past 5 years? Since 2000?]

ALLOW PARTICIPANT TO LIST THE DIFFERENT ORGANIZATION LEVEL POLICIES; ENTER ONE POLICY NAME AT A TIME – FOR EACH ADDITIONAL POLICY, ADD A ROW.

____________________________

ADD A ROW FOR EACH NEW P OLICY

B22.

*

What specific changes to the physical environment were made to promote healthy nutrition? [In the past 5 years? Since 2000?]

ALLOW PARTICIPANT TO LIST THE DIFFERENT ORGANIZATION LEVEL ENVIRONMENTAL CHANGE; ENTER ONE CHANGE AT A TIME – FOR EACH ADDITIONAL CHANGE, ADD A ROW.

____________________________

ADD A ROW FOR EACH NEW E NVIRONMENTAL CHANGE

CONTINUE TO SECTION C: PROGRAMS AND POLICIES.

This form represents the one module that should be completed for each individual PROGRAM / POLICY (as listed in SECTION B) and will have information provided via Key Informant Interview AND via document abstraction. With each new key informant interview/ document abstraction, this one module should be added to/updated.

This section – SECTION C – is also to be used by the Community Documenter within the RIPA communities to conduct quarterly program updates (noting new programs and updates to existing programs) with the respective program Key Informant.

* Question to also be asked or documented during the Follow-up (In-Person, Telephone, or Website) Interview: Responses to be based on changes and updates since the previous interview (section introductions and question wording will be amended accordingly).

SECTION C

*

INDICATE INFORMATION SOURCE

KEY INFORMANT 1

DOCUMENT...(SKIP TO Q.D38) 2

*

PROGRAM / POLICY STUDY ID

*

PROGRAM / POLICY NAME

________________________________

GENERAL (PROGRAM/POLICY) QUESTIONS

[INTERVIEWER: HAND KEY INFORMANT RESPONSE CHOICES CARD FOR AID IN ANSWERING QUESTIONS IN THIS AND SUBSEQUENT SECTIONS; FOR REMOTE INTERVIEWS, [SHOW MAP OR ASK RESPONDENT TO REFER TO MAP SENT VIA POST- OR E-MAIL].

C1.

*

What was the onset or beginning date of this (program/policy)?

/ /

MONTH DAY YEAR

REFUSED 7

DON’T KNOW 8

C2.

*

What was the duration of the activity?

READ ANSWERS. SELECT ONLY ONE.

One-time event 1

More than once 2

REFUSED 7

DON’T KNOW 8

C3.

*

Is this ongoing or still in operation?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

IF Q.C3 = 2, ASK Q.C3a. ELSE SKIP TO Q.C4

C3a. When did it end?

*

/ /

MONTH DAY YEAR

REFUSED 7

DON’T KNOW 8

C4.

*

IS THIS A PROGRAM OR A POLICY?

PROGRAM 1

POLICY 2

IF Q.C4 = 2, ASK Q.C4a and Q.C4b; ELSE SKIP TO C5

C4a. What was the number of participants who were potentially affected by this policy?

*

REFUSED 7

DON’T KNOW 8

C4b. What was the number of people who were actually affected by this policy?

*

REFUSED 7

DON’T KNOW 8

SKIP TO Q.C9

C5.

*

What was the number of participants who received or took part in the program?

REFUSED 7

DON’T KNOW 8

C6.

*

What was the percent of the population who received or took part in the program?

%

REFUSED 7

DON’T KNOW 8

C7.

*

With what frequency was the program delivered to the targeted population?

# times per

DAY 1

WEEK 2

MONTH 3

YEAR 4

REFUSED 7

DON’T KNOW 8

C8.

*

With what duration was the program delivered to the targeted population?

# times per

DAY 1

WEEK 2

MONTH 3

YEAR 4

REFUSED 7

DON’T KNOW 8

C9.

*

Please describe the (program name/policy name). Briefly describe who, did what, with whom, and with what intended result.

_____________________________

C10.

*

What goal (and related objective and approach) was addressed by this (program/policy)? READ ANSWERS. SELECT ONLY ONE.

Improve Nutrition 1

Increase Physical Activity 2

Both 3

Other 4

REFUSED 7

DON’T KNOW 8

IF Q.C10 = 1, ANSWER Q.C11 – Q.C13, THEN SKIP TO Q.C17; IF Q.C10 = 2, SKIP TO Q.C14 [INCREASE PHYSICAL ACTIVITY RELATED QUESTIONS]; IF Q.C10 = 3, CONTINUE TO C11; IF Q.C10 = 4, SKIP TO Q.C17.

IMPROVE NUTRITION RELATED QUESTIONS

C11.

*

What were the key behavioral objectives?

You may select more than one answer from the list.

READ ANSWERS.

Increase consumption of fruits

and vegetables 1

Increase consumption of wholegrain foods such as breads, rice, pasta, cereals 2

Increase eating breakfast 3

Increase consumption of water 4

Decrease consumption of sugar sweetened beverages 5

Decrease consumption of fast food 6

Decrease consumption of fat 7

Decrease consumption of high calorie snacks, desserts, sweets, and candy 8

Decrease calories from all food 9

Increase breastfeeding/improve

infant health 10

Other 11

REFUSED 97

DON’T KNOW 98

C12.

*

Which of the following CDC Community Strategies were used? You may select more than one answer from the list.

READ ANSWERS.

Increase availability of healthier

food and beverage choices 1

Improve affordability of healthier

food and beverage choices 2

Improve geographic availability

of supermarkets/ food retailers

in underserved areas 3

Improve production, distribution,

and procurement of foods from

local farms 4

Restrict availability of less healthy

foods and beverages 5

Institute smaller portion size options 6

Limit advertisements of less healthy

foods and beverages 7

Increase support for breastfeeding 8

Other 9

Not Applicable 10

REFUSED 97

DON’T KNOW 98

C13.

*

Which of the following CDC MAPPS Strategies were used? You may select more than one answer from the list.

READ ANSWERS.

NOTE OF CLARIFICAITON: MAPPS Strategies refer to a community’s use of Media, Access, Point Of Decision, Price, And Social Support/Services in helping to change the social and physical environment to positively assist an individual in making healthier lifestyle choices.

Use media to promote healthy foods/drinks 1

Restrict advertising and employ

counter-advertising for unhealthy

foods/ drinks 2

Increase access to healthy food/

drink choices 3

Reduce the availability of unhealthy foods/drinks 4

Use point of decision labeling/

signage/ placement to increase consumption of healthy foods/drinks 5

Use price to benefit consumption

of healthy foods/drinks 6

Use social support/services to

promote breastfeeding 7

Other 8

None of the above 9

REFUSED 97

DON’T KNOW 98

INCREASE PHYSICAL ACTIVITY RELATED QUESTIONS

C14.

*

What were the key behavioral objectives?

You may select more than one answer from the list.

READ ANSWERS.

Increase walking or biking to/

from school 1

Increase exposure to physical

education (i.e., frequency and/or

duration of classes) 2

Increase moderate to vigorous

physical activity in PE classes 3

Increase physical activity during

school recess or classroom

instruction 4

Increase participation in school

sports teams 5

Increase participation in

community-based sports teams 6

Increase participation in

community-based physical activity lessons, classes, or clubs 7

Increase participation in home/

family physical activity 8

Increase physical activity in

after school programs 9

Decrease TV watching 10

Decrease recreational computer/

internet use 11

Decrease time spent playing

inactive video/ handheld

electronic games 12

Other 13

REFUSED 97

DON’T KNOW 98

C15.

*

Which of the following CDC Community Strategies were used? You may select more than one answer from the list.

READ ANSWERS.

Require physical education in

schools 1

Increase the amount of physical

activity in physical education

programs in schools 2

Increase opportunities for

extracurricular physical activity 3

Reduce screen time in public

service venues 4

Improve access to outdoor

recreational facilities 5

Enhance infrastructure supporting bicycling 6

Enhance infrastructure supporting

walking 7

Support locating schools within easy walking distance of residential areas 8

Improve access to public

Transportation 9

Zone for mixed use development 10

Enhance personal safety in areas

where persons are or could be

physically active 11

Enhance traffic safety in areas

where persons are or could be

physically active 12

Participate in community coalitions

or partnerships to address obesity 13

Other 14

None of the above 15

REFUSED 97

DON’T KNOW 98

C16. *

Which of the following CDC MAPPS Strategies were used?

You may select more than one answer from the list.

READ ANSWERS.

Use media to increase activity 1

Increase access to safe locations

to be active and improve the built environment 2

Use of point of decision labeling/

signage/ placement to prompt

physical activity 3

Use social support/services to

promote increased activity 4

Other 5

None of the above 6

REFUSED 97

DON’T KNOW 98

I’d now like to ask you about Behavior Change Strategies used by this (program/policy). And, I’d like to ask you about which Behavior Change Strategies were used for each year the program (has been/was) implemented.

C17.

*

How many years (has/was) the (program/policy) implemented?

Years

REFUSED 97

DON’T KNOW 98

Q.C18 – Q.C20: YEAR 1 of Implementation: Behavior Change Strategies Used AND Reach and Level of Implementation

ADD A SECTION (of questions, Q.D18-Q.D20) FOR EACH ADDITIONAL YEAR OF IMPLEMENTATION.

C18.

*

Which of the following Behavior Change Strategies were used?

You may select more than one answer from the list. READ ANSWERS.

For each Behavior Change Strategy used, describe how it was implemented, in Q.D18a.

Providing information and

enhancing skills 1

Enhancing services and support 2

Modifying access, opportunities,

and barriers 3

Changing consequences 4

Modifying policies and broader

systems 5

Other 6

REFUSED 7

DON’T KNOW 8

C18a. Description of how behavior change strategies were used.

*

_____________________________

C19.

*

What is the estimated percentage of the population (i.e., children/adults in school district) who received or was exposed to the community (program/policy)?

READ ANSWERS. SELECT ONLY ONE.

0-5% 1

5-25% 2

25-50% 3

50-75% 4

75-100% 5

REFUSED 97

DON’T KNOW 98

C20.

*

What is the estimated level or degree to which this community (program/policy) was actually implemented in the community?

READ ANSWERS. SELECT ONLY ONE.

Low (0-33%) 1

Medium (34-66%) 2

High (67-100%) 3

REFUSED 97

DON’T KNOW 98

C21.

*

Describe how the (program/policy) was adapted or (re)designed to fit the culture and context of the community.

_____________________________

C22.

*

What were the targeted groups whose behavior was to be changed by the community (program/policy)?

You may select more than one answer from the list.

READ ANSWERS.

Children 1

Parents/Caregivers 2

Child care providers 3

Teachers 4

Appointed/Elected officials 5

Community members 6

Food service personnel 7

Health care providers 8

Other 9

REFUSED 97

DON’T KNOW 98

C23.

*

What were the ages of these groups targeted by the community (program/policy)?

You may select more than one answer from the list.

READ ANSWERS.

Infants 0-2 1

Early childhood 3-5 2

Children 6-11 3

Adolescents 12-19 4

Adults 20-older 5

REFUSED 97

DON’T KNOW 98

C24.

*

What was the primary gender of the group(s) targeted by the community (program/policy)?

You may select more than one answer from the list.

READ ANSWERS.

Male 1

Female 2

All 3

REFUSED 97

DON’T KNOW 98

C25.

*

What was the primary income level of the group(s) targeted by the community (program/policy)? You may select more than one answer from the list. READ ANSWERS.

Low-Income 1

All 2

REFUSED 97

DON’T KNOW 98

C26.

*

What were the primary racial/ethnic groups to benefit from the community (program/policy).

You may select more than one from the list.

WHITE 1

BLACK/ AFRICAN AMERICAN 2

AMERICAN INDIAN 3

ALASKAN NATIVE 4

NATIVE HAWAIIAN 5

GUAMANIAN 6

SAMOAN 7

OTHER PACIFIC ISLANDER (SPECIFY) 8

ASIAN INDIAN 9

CHINESE 10

FILIPINO 11

JAPANESE 12

KOREAN 13

VIETNAMESE 14

OTHER ASIAN (SPECIFY) 15

AMERICAN 16

SOME OTHER RACE (SPECIFY) 17

REFUSED 97

DON’T KNOW 98

SPECIFY:

_____________________________

C27.

*

Where or in what place (5 digit zip code; County/State) did this community (program/policy) primarily take place?

[SHOW MAP WITH ZIP CODES INCLUDED IN THE HIGH SCHOOL CATCHMENT AREA; OR ASK RESPONDENT TO REFER TO MAP SENT VIA POST- OR E-MAIL].

_____________________________

C28.

*

What primary setting did this community (program/policy) affect? You may select more than one answer from the list.

READ ANSWERS.

Business 1

Child care/Preschool sites 2

Community Organizations 3

Criminal Justice 4

Faith-based organizations 5

Food retailers 6

Health care organizations 7

Health Department – Local 8

Health Department – State 9

Home 10

Other Government Organizations 11

Media 12

Neighborhood 13

Parks and Recreation 14

Schools 15

Transportation 16

Youth Organizations 17

Other 18

REFUSED 97

DON’T KNOW 98

C29.

*

At what level is this community (program/policy) intended to have the most effect?

READ ANSWERS. SELECT ONLY ONE.

Individual 1

Family/Interpersonal 2

Organization 3

Community 4

Broader System 5

REFUSED 7

DON’T KNOW 8

C30.

*

What key social determinants or contributors to health disparities were addressed by this community (program/policy)? You may select more than one answer from the list.

READ ANSWERS.

Access to healthcare 1

Community power/influence 2

Crime/safety 3

Education 4

Employment 5

Housing 6

Poverty/income inequality 7

Racism/discrimination 8

Social cohesion/connectedness 9

Transportation 10

None 11

Other 12

REFUSED 97

DON’T KNOW 98

C31.

*

What people or groups (e.g., coalition, partnership) worked together to bring about this community [program/policy]?

_____________________________

I’d now like to ask you some questions about funding for this (program/policy) and will ask a series of questions for each type of funding you received.

ADD A SECTION (for Q.D32 – QD.36) FOR EACH ADDITIONAL FUNDING SOURCE.

C32.

*

What is the name of the funding source?

_____________________________

C33.

*

What type of funding source is/was this? READ ANSWERS. SELECT ONLY ONE.

Local Government 1

State Government 2

Federal Government 3

Other Government 4

Non-Profit Foundation 5

Non-Profit Community

Organization 6

Other Non-Profit 7

REFUSED 97

DON’T KNOW 98

C34.

*

How much funding was devoted to this (program/policy)?

$

REFUSED 97

DON’T KNOW 98

C35.

*

When did the funding start?

/ /

MONTH DAY YEAR

REFUSED 97

DON’T KNOW 98

C36.

*

When did the funding end?

/ /

MONTH DAY YEAR

REFUSED 97

DON’T KNOW 98

C37.

*

Is there another person or persons in your organization with more knowledge about this [program/policy] that we should be sure to talk with?

ADD A QUESTION FOR EACH NEW CONTACT PROVIDED.

YES 1

NO 2

REFUSED 97

DON’T KNOW 98

IF Q.C37 = 1, COMPLETE Q.C37a FOR EACH ADDITIONAL CONTACT.

ELSE SKIP TO DOCUMENT ABSTRACTION (Q.C38).

C37a. Please provide the name and contact information for the person we should contact about this (program/policy).

*

_____________________________

DOCUMENT REVIEW/ ABSTRACTION

We are also interested in examining documents that may help identify types of changes in community programs and policies. The types of documents we are interested in reviewing are:

• Publicly available legislative hearing documents;

• Annual Program Reports;

• Management Information System (MIS) Reports often used by funders;

• Available and relevant RFPs that may have been released within the time frame of interest;

• Agency-wide reports such as Healthy People 2000 and 2010;

• Coalition Reports from relevant organizations; and

• School, other institutional, and community wellness policies.

C38.

*

HAVE ANY DOCUMENTS RELATED TO THIS PROGRAM BEEN ADDEDTO THE DOCUMENT LIST BELOW?

YES…(SKIP TO D39) 1

NO…..(READ D38a) 2

C38a. We would greatly appreciate it if you could make any of these types of key documents available to us.

*

FOR EACH DOCUMENT RECEIVED BY KEY INFORMANT, ADD A ROW TO Q.C39.

Following is a list of documents and a brief description we have received and reviewed related to this (program/policy). Can you please tell me if the list is accurate and complete, and whether the description is appropriate? Please feel free to correct any information we have listed. READ LIST AND DESCRIPTION.

ADD A SECTION (of questions QC39 – QC42) FOR EACH ADDITIONAL DOCUMENT RECEIVED.

C39.

*

The name of the document is: READ ANSWER.

_____________________________

C40.

*

HAS THIS DOCUMENT BEEN ABSTRACTED YET?

YES 1

NO… (SKIP TO NEXT DOCUMENT) 2

C41.

*

This document is a: READ ANSWER.

Brochure 1

Booklet 2

Annual Report 3

Legislative Document 4

MIS Report 5

Local Government Report 6

State Government Report 7

Coalition Report 8

School Report 9

Other 10

Specify:

_____________________________

C42. *

The document description we have on file is: READ ANSWER.

Please provide additional comments.

_____________________________

I would like to ask you a few overall questions about the contributions of your organization’s programs/ policies/ environmental changes we discussed today, and the factors in your community or context that made it easier or more difficult to implement them.

C43.

*

How do the programs/policies you identified contribute to promoting physical activity, healthy nutrition, and/or healthy weight; that is, how do you see these activities influencing the behaviors of healthy nutrition and physical activity among children and youth?

____________________________

C44.

*

What facilitating factors of the context or situation made it easier to bring about and implement these community programs/policies?

____________________________

C45.

*

What restraining factors of this context or situation made it more difficult to bring about and implement these community programs/policies?

____________________________

More specifically, we would like to ask you about some particular aspects of the context or situation that might have affected the community’s efforts to promote physical activity, healthy nutrition, or healthy weight among children and youth.

C46.

*

What is the level of awareness about the issue and actions to address it in the community? READ ANSWERS. SELECT ONLY ONE.

Low 1

Medium 2

High 3

REFUSED 7

DON’T KNOW 8

C47.

*

Please explain why you selected the answer you did.

___________________________

C48.

*

What is the level of leadership in the community to address this issue? READ ANSWERS. SELECT ONLY ONE.

Low 1

Medium 2

High 3

REFUSED 7

DON’T KNOW 8

C49.

*

Please explain why you selected the answer you did.

___________________________

C50.

*

What is the level of collaboration or working together in the community to address this issue?

READ ANSWERS. SELECT ONLY ONE.

Low 1

Medium 2

High 3

REFUSED 7

DON’T KNOW 8

C51.

*

Please explain why you selected the answer you did.

___________________________

C52.

*

What is the level of planning for action to address this issue?

READ ANSWERS. SELECT ONLY ONE.

Low 1

Medium 2

High 3

REFUSED 7

DON’T KNOW 8

C53.

*

Please explain why you selected the answer you did.

___________________________

C54.

*

What is the level of resources available in the community to address this issue? READ ANSWERS. SELECT ONLY ONE.

Low 1

Medium 2

High 3

REFUSED 7

DON’T KNOW 8

C55. *

Please explain why you selected the answer you did.

___________________________

IF SPEAKING TO A KEY INFORMANT OF A SPECIAL JOB TITLE CATEGORY (PER SECTION A, Q.9), CONTINUE TO SECTION D [N/A FOR FOLLOW-UP INTERVIEW]; ELSE, END THE INTERVIEW.

This is the last of the questions that I have for you. I really appreciate your time today. If you think of anything else, please feel free to contact me. Here is my card. When I get back to my office, I will be reviewing the notes I have made. If I have any additional questions, I will contact you via the information you provided at the beginning of this interview. Again, thank you very much for your time. The information you have provided is very useful, and we are very appreciative of your time. Good bye!
	*RECORD TIME INTERVIEW ENDED		: AM / PM

The questions in this section – SECTION D – are specific addendum questions to be asked of Key Informants serving in particular job titles/ categories as indicated in Section A and presented below. This section is part of the BASELINE INTERVIEW PROTOCOL ONLY.

THE FOLLOWING QUESTIONS, (Q.D1 – Q.D4), WHICH ARE RELATED TO PHYSICAL ACTIVITY EFFORTS WITHIN THE COMMUNITY, ARE TO BE ASKED OF A KEY INFORMANT WHO IS EITHER: PARKS AND RECREATION ADMINISTRATOR/STAFF MEMBER (Q.A9 = 1) OR URBAN PLANNER (Q.A9 = 2).

I would now like to ask you questions about the parks within our study catchment area [SHOW MAP OR ASK RESPONDENT TO REFER TO MAP SENT VIA POST- OR E-MAIL], and specifically, about the features and amenities at these parks.

D1.

Are there any parks within the catchment area that have any of the following features?

READ ANSWERS. CODE ALL THAT APPLY.

Playground/Tot lot 1

Swimming pool deeper

than 3 feet deep 2

Wading pool less than

3 feet deep 3

Basketball court 4

Walking path 5

Running track 6

Bicycle trail 7

Single or Multipurpose field 8

Skate park 9

Streetlights 10

Floodlights 11

On-site community center 12

REFUSED 97

DON’T KNOW 98

D2.

Do the parks in this area generally have a reputation for being safe, unsafe, or a mix of safe and unsafe?

READ ANSWERS. SELECT ONLY ONE.

Safe 1

Unsafe 2

Mix of safe and unsafe 3

REFUSED 97

DON’T KNOW 98

D3.

Do you think the operating budget for the parks is sufficient to provide regular maintenance at all parks?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

D4.

Are there additional people we should talk to related to: (1) efforts to plan programs or events to promote physical activity at the parks; (2) understanding physical changes to the community environment; or (3) the physical features at local parks?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

IF Q.D4 = 1, COMPLETE Q.D4a FOR EACH CONTACT. ELSE SKIP TO Q.D5.

D4a. Please provide the name and contact information for the individuals we should contact.

_______________________________

IF SPEAKING WITH THE SCHOOL PRINCIPAL (Q.A9 = 5), COMPLETE ALL REMAINING QUESTIONS;

IF SPEAKING WITH THE SCHOOL HEALTH COORDINATOR (Q.A9 = 7), COMPLETE Q.D5 – Q.D16.

IF SPEAKING WITH THE SCHOOL PHYSICAL ACTIVITY COORDINATOR (Q.A9 = 8), SKIP TO Q.D17.

I would now like to ask you some additional questions related to nutrition efforts in your school.

D5.

What was the average daily attendance for the (current or most recent) school year at this school? RECORD A NUMBER, NOT A PERCENT.

DAILY

ATTENDANCE

D6.

For how long and to what extent is nutrition instruction required for all grade levels for a specified number of hours? READ ANSWERS.

NUMBER OF YEARS

Not at all 1

To some extent 2

To a large extent 3

Completely 4

REFUSED 7

DON’T KNOW 8

D7.

For how long and to what extent has this school implemented a comprehensive, sequential nutrition education program that includes all grade levels? READ ANSWERS.

NUMBER OF YEARS

Not at all 1

To some extent 2

To a large extent 3

Completely 4

REFUSED 7

DON’T KNOW 8

D8.

For how long and to what extent does a team meet on a regular basis to plan or review a comprehensive nutrition education program or curriculum? READ ANSWERS.

NUMBER OF YEARS

Not at all 1

To some extent 2

To a large extent 3

Completely 4

REFUSED 7

DON’T KNOW 8

D9.

For how long and to what extent have nutrition instruction materials been selected based on health education content standards? READ ANSWERS.

NUMBER OF YEARS

Not at all 1

To some extent 2

To a large extent 3

Completely 4

REFUSED 7

DON’T KNOW 8

D10.

For how long and to what extent have the Nutrition Education Goals of the local wellness policy been implemented at this school?

READ ANSWERS.

NUMBER OF YEARS

Not at all (<10%) 1

To some extent (10-50%) 2

To a large extent (50-90%) 3

Completely (>90%) 4

REFUSED 7

DON’T KNOW 8

D11.

For how long and to what extent have Physical Activity Goals of the local wellness policy been implemented at this school? READ ANSWERS.

NUMBER OF YEARS

Not at all (<10%) 1

To some extent (10-50%) 2

To a large extent (50-90%) 3

Completely (>90%) 4

REFUSED 7

DON’T KNOW 8

D12.

How does this school compare to other schools of the same level [elementary, middle, high] in the district with regard to implementation of the nutrition components of the wellness policy? READ ANSWERS.

Less fully implemented

than most 1

About the same as most 2

More fully implemented

than most 3

There are no other schools

at our level in the district 4

REFUSED 7

DON’T KNOW 8

D13.

How often did your school health or wellness council, committee, or team meet during the past 12 months? READ ANSWERS.

Did not meet 1

1-2 times 2

3-4 times 3

5-6 times 4

>6 times 5

N/A – we have only a district

level health/ wellness committee.. (SKIP TO C24) 6

N/A – we have no district

or school level health/ wellness committee….(SKIP TO C24) 7

REFUSED 97

DON’T KNOW 98

D14.

For how many years has this school health or wellness council, committee, or team been meeting on a regular basis?

NUMBER YEARS

refused 97

don’t know 98

D15.

Currently, does someone in your district or school coordinate school health or wellness, for example, a school health coordinator? READ ANSWERS.

At both 1

At district only 2

At school only 3

At neither 4

refused 97

don’t know 98

D16.

How long has this school had someone in this position?

NUMBER YEARS

NUMBER MONTHS

refused 97

don’t know 98

I would now like to ask you some additional questions about your school’s policies and practices related to physical activity and/or physical education.

In the past 12 months, has your school…

D17a.

Sought positive media attention for physical education?

YES 1

NO 2

refused 7

don’t know 8

D17b.

Provided families of all students with information on physical activity?

YES 1

NO 2

refused 7

don’t know 8

D17c.

Offered school-wide physical activity or sports events, such as fun runs, to families of all students?

YES 1

NO 2

refused 7

don’t know 8

D17d.

Provided awards or recognition for outstanding physical activity programs, such as intramural or interscholastic sports programs?

YES 1

NO 2

refused 7

don’t know 8

During the past 12 months, has your school collaborated on physical activity programs with any of the following?

D18a.

A local health department.

YES 1

NO 2

refused 7

don’t know 8

D18b.

A local hospital.

YES 1

NO 2

refused 7

don’t know 8

D18c.

A local mental health or social services agency.

YES 1

NO 2

refused 7

don’t know 8

D18d.

A health organization, such as the American Heart Association or American Cancer Society.

YES 1

NO 2

refused 7

don’t know 8

D18e.

A local college or university.

YES 1

NO 2

refused 7

don’t know 8

D18f.

A local business.

YES 1

NO 2

refused 7

don’t know 8

D18g.

A local parks or recreation department.

YES 1

NO 2

refused 7

don’t know 8

D18h.

A local youth organization, such as the Boys and Girls Clubs.

YES 1

NO 2

refused 7

don’t know 8

D18i.

Alliance for a Healthier Generation.

YES 1

NO 2

refused 7

don’t know 8

D18j.

A local service club, such as the Rotary Club.

YES 1

NO 2

refused 7

don’t know 8

D18k.

A local health or fitness club.

YES 1

NO 2

refused 7

don’t know 8

D18l.

A local professional sports team.

YES 1

NO 2

refused 7

don’t know 8

D18m.

A local department of transportation or public works.

YES 1

NO 2

refused 7

don’t know 8

D18n.

A local law enforcement agency.

YES 1

NO 2

refused 7

don’t know 8

The next questions ask about the use of physical activity as punishment or bad behavior and excluding students from physical activity or physical education as punishment for bad behavior.

D19.

Has your school adopted a policy that prohibits teachers from excluding students from all or parts of recess as punishment for bad behavior or failure to complete class work?

YES 1

NO 2

refused 7

don’t know 8

D20.

Has your school adopted a policy that prohibits teachers from using physical activity, for example running/walking laps or pushups, to punish students for bad behavior?

YES 1

NO 2

refused 7

don’t know 8

D21.

Has your school adopted a policy prohibiting physical education teachers from excluding students from all or part of physical education as a punishment for bad behavior?

YES 1

NO 2

refused 7

don’t know 8

The last few questions ask about your school’s active transport policies and practices.

Does your school do any of the following activities to support or promote walking or biking to and from school?

D22a.

Use paid or volunteer crossing guards.

YES 1

NO 2

refused 7

don’t know 8

D22b.

Use a walking school bus (a walking school bus is a group of children walking to or from school with one or more adults).

YES 1

NO 2

refused 7

don’t know 8

D22c.

Use law enforcement officials to promote traffic safety near the school.

YES 1

NO 2

refused 7

don’t know 8

D22d.

Use law enforcement officials to prevent crime near the school.

YES 1

NO 2

refused 7

don’t know 8

D22e.

Provide bicycle racks at school.

YES 1

NO 2

refused 7

don’t know 8

D22f.

Provide promotional materials to students or parents such as safety tips or maps of bicycle or walking routes to schools.

YES 1

NO 2

refused 7

don’t know 8

D22g.

Use traffic calming devices to slow driving speeds near the school.

YES 1

NO 2

refused 7

don’t know 8

D22h.

Use reduced speed limits in a specified school zone during peak school travel times.

YES 1

NO 2

refused 7

don’t know 8

D23.

On an average school day, what percent of students walk or bike TO your school in the morning?

READ ANSWERS.

0-20% 1

21-40% 2

41-60% 3

61-80% 4

More than 80% 5

refused 7

don’t know 8

D24.

On an average school day, what percent of students walk or bike home (or to some other destination) FROM your school in the afternoon? READ ANSWERS.

0-20% 1

21-40% 2

41-60% 3

61-80% 4

More than 80% 5

refused 7

don’t know 8

D25.

Does your school prohibit students from walking or biking to or from school?

YES 1

NO 2

refused 7

don’t know 8

This is the last of the questions that I have for you. I really appreciate your time today. If you think of anything else, please feel free to contact me. Here is my card. When I get back to my office, I will be reviewing the notes I have made. If I have any additional questions, I will contact you via the information you provided at the beginning of this interview. Again, thank you very much for your time. The information you have provided is very useful, and we are very appreciative of your time. Good bye!
	*RECORD TIME INTERVIEW ENDED		: AM / PM

Key Informant Interview

Sources and References



1. Fawcett, S. B., V. T. Francisco, D. Hyra, A. Paine-Andrews, J. A. Schultz, S. Russos, J. L. Fisher and P. Evensen. 2000. Building healthy communities. p. 75-93. In A. Tarlov and R. S. Peters (ed.), Society and population health: A state perspective. New Press. New York, NY.

2. Fawcett, S. B., V. T. Francisco, A. Paine-Andrews, R. K. Lewis, K. P. Richter, K. J. Harris, E. L. Williams, J. Y. Berkley, J. A. Schultz, J. L. Fisher and C. M. Lopez. 1993. Work Group evaluation handbook: Evaluating and supporting community initiatives for health and development. Work Group on Health Promotion and Community Development, University of Kansas. Lawrence, KS.

3. Fawcett, S. B., A. Paine-Andrews, V. T. Francisco, J. Schultz, K. P. Richter, J. Berkley-Patton, J. L. Fisher, R. K. Lewis, C. M. Lopez, S. Russos, E. L. Williams, K. J. Harris and P. Evensen. 2001. Evaluating community initiatives for health and development. WHO Reg Publ Eur Ser. (92):241-270.

4. Fawcett, S. B., A. Paine-Andrews, V. T. Francisco, J. A. Schultz, K. P. Richter, R. K. Lewis, E. L. Williams, J. Y. Berkley, C. M. Lopez and J. L. Fisher. 1996. Empowering community health initiative through evaluation. p. 161-187. In D. M. Fetterman, S.J. Kafterian, and A. Wandersman (ed.), Empowerment evaluation: Knowledge and tools for self-assessment and accountablility. Sage Publications. Thousand Oaks.

5. Fawcett, S. B., J. A. Schultz, V. Carson, V. Renault and V. T. Francisco. 2003. Using Internet Based Tools to Build Capacity for Community-Based Participatory Research and Other Efforts to Promote Community Health and Development. p. 155-178. In M. Minkler, N. Wallerstein (ed.), Community-Based Participatory Research for Health. Jossey-Bass. San Francisco.

6. Fawcett, S. B., T. D. Sterling, A. Paine-Andrews, K. J. Harris, V. T. Francisco, K. P. Richter, R. K. Lewis and T. L. Schmid. 1995. Evaluating community efforts to prevent cardiovascular disease. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Atlanta, GA.

7. Francisco, V. T., A. L. Paine and S. B. Fawcett. 1993. A methodology for monitoring and evaluating community health coalitions. Health Educ Res. 8(3):403-416.

8. Goodman, R. M., L. C. Liburd and A. Green-Phillips. 2001. The formation of a complex community program for diabetes control: lessons learned from a case study of Project DIRECT. J Public Health Manag Pract. 7(3):19-29.

9. Goodman, R. M., M. A. Speers, K. McLeroy, S. B. Fawcett, M. Kegler, E. A. Parker, S. R. Smith, T. D. Sterling and N. Wallerstein. 1998. Identifying and defining the dimensions of community capacity to provide a basis for measurement. Health Educ Behav. 25(3):258-278.

10. Paine-Andrews, A., J. L. Fisher, P. J. Berkley, S. B. Fawcett, E. L. Williams, R. K. Lewis and K. J. Harris. 2002. Analyzing the contribution of community change to population health outcomes in an adolescent pregnancy prevention initiative. Health Educ Behav. 29(2):183-193.

11. Paine-Andrews, A., K. J. Harris, S. B. Fawcett, K. P. Richter, R. K. Lewis, V. T. Francisco, J. Johnston and S. Coen. 1997. Evaluating a Statewide Partnership for Reducing Risks for Chronic Diseases. Journal of Community Health. 22(5):343.



1 This master version of the key informant consent form contains shaded wording indicating where sentences or phrases will differ as appropriate according to the type of community.

2 This master version of the key informant verbal consent script contains shaded wording indicating where sentences or phrases will differ as appropriate according to the type of community.

3 This master version of the post baseline new/replacement key informant consent script contains shaded wording indicating where sentences or phrases will differ as appropriate according to the type of community.

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