Public Health Practice Stories from the Field

ATTACHMENT – A: Data Collection Instrument Form approved

OMB No. 0920-0879

Expiration date: 03/31/2014

Public Health Practice Stories from the Field

Story Collection Template

CDC’s Office for State, Tribal, Local and Territorial Support (OSTLTS) disseminates stories about the implementation of public health practices in the field. These stories, Public Health Practice Stories from the Field (PHPSFF), span a broad range of public health, performance management, and quality improvement topics.

This template is a form for collecting and formatting the content for a PHPSFF. It should be used to draft stories for the PHPSFF series. Word limits are included as guidelines. Each section is followed by a self-check, which outlines criteria relevant to that section.

The story collection template may be shared with partners that collect and draft stories on behalf of OSTLTS.

Submission Instructions

• Fill out the PHPSFF template.

• Make sure all the information provided is reviewed and approved by the source (STLT health agency) before submission.

• Submit your completed story template to [email protected].

OSTLTS will edit the story for consistency with PHPSFF criteria and may request additional information if clarification is needed. OSTLTS will provide the final draft of the story to you for final approval before posting on the State, Tribal, Local and Territorial Public Health Gateway.

Visit the State, Tribal, Local and Territorial Public Health Gateway for more information about PHPSFF and to view and download all of the current stories.

Public reporting burden of this collection of information is estimated to average 7 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0879).

PHPSFF – Story Collection Template

General Style Guidelines

• Use plain language; avoid jargon.

• Keep messages simple and concise. A bulleted list of key points is acceptable.

• Use active voice (e.g., “X partner provided Y trainings.”) instead of passive voice (e.g., “Trainings were provided.”).

• Limit use of acronyms. If you use acronyms, spell them out on first mention.

• Include direct quotes if they strengthen the story.

• Do not interject an opinion unless you attribute it to someone.

• Avoid broad, sweeping statements (e.g., “A significant amount of money was saved”).
  Be specific.

Title

Self-check: Have you

• Captured the overall message of the story?

• Included an action verb?

• Captured the reader’s attention?

Public Health Problem or Performance/Quality Improvement Issue (200 words or less)

Self-check: Have you

• Described the scope of the public health problem in your jurisdiction or introduced the problem that performance management /quality improvement addressed?

• Explained why this public health problem or quality improvement issue is important?

• Used data (include references) to frame the problem, including health burden and economic costs?

• Specified the affected population(s)?

Program / Activity Description and Methodology (200 words or less)

Self-check: Have you

• Described how the practice, program, or activity was implemented, including where and when it took place and how it addressed the problem?

• Described the specific methodology or quality improvement tools used as applicable?

• Identified who was involved, including your partners?

• Identified the target audience of the practice, program, or activity?

• Identified the evidence-base for the practice, program, or activity or described how it is an innovative practice, program, or activity?

Accomplishments and Impact (200 words or less)

Self-check: Have you

• Described how progress of the practice, program, or activity was evaluated or how progress will be evaluated?

• Identified the short-term or intermediate outcomes (include data) that demonstrate how the practice, program, or activity addressed the problem (e.g., change in policy, change in local-level practices, establishment of additional funding)?

• Included specific numbers to illustrate the scope of the impact (e.g., X of XX health departments, # of days saved in reporting to CDC)?

Conclusions/Lessons Learned (200 words or less)

Self-check: Have you

• Provided a conclusion to the story that avoids using broad, sweeping statements such as “There was a noticeable decrease in prescription medication abuse”?

Additional Information

1. List keywords and keyword phrases specific to this story in the box below.

2. Check if any of the following are being submitted to complement your story:

• Testimonials

• Quote from partner/participant

• Sample of materials produced

• Press release

• Promotional materials

• Project photo(s)

• Publication (e.g., news story, journal article)

• Video/audio clip

• Website URL

• Other — Explain:

3. Contact information

Name:

Title:

Organization:

Phone:

E-mail:

4. Does OSTLTS have permission to share this story?

• Yes

• No

5. Confirm that this information has been cleared for dissemination by your agency.

• Yes, I confirm this has been cleared.

• No. (Please note that this information must be cleared by your agency before it is submitted to OSTLTS.)

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Last updated: 01.18.12