D - Data collection instrument - word version

Attachment D: Data Collection Instrument: MS Word version

Form Approved

OMB No. 0920-0879

Expiration Date: 03/31/2014

Assess Breast and Cervical Cancer Screening Program Activities to

Expand Access to Screening

The Centers for Disease Control and Prevention (CDC), Division of Cancer Prevention and Control (DCPC) is assessing how state, tribal and territorial health departments implemented the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) in DP1205 program year 1, the time period July 1, 2012 through June 30, 2013.

Specifically, the purpose of this data collection is to better understand how you are implementing your BCCEDP programs to an expanded target population within an evolving healthcare context and to collect information about your training and technical assistance needs. Your feedback is extremely important. Your responses to the questions are voluntary, anonymous, and will be kept in a secure manner. Results will be incorporated into individual and summary grantee reports for you and other stakeholders.

CDC will NOT use these data to make funding decisions. These data will provide a baseline on the activities you are implementing. Given the evolving health care context, we expect that grantees will make changes in the types of activities implemented over the course of the DP1205 5-year program. We do NOT expect that any program will be doing all of the activities asked about in this data collection.

Thank you for your participation.

INSTRUCTIONS

WHO SHOULD COMPLETE THIS DATA COLLECTION? The person responsible for the day-to-day management of the program and/or with the most program knowledge should complete this data collection. Topics covered include: respondent information, program activities, clinical service delivery, evaluation, non-screening partnerships, data use, training and technical assistance and program management.

WHAT TIME PERIOD IS BEING ASSESSED? We are collecting information about the implementation of your DP1205 BCCEDP, program year 1 (PY1). Unless instructed otherwise, all responses should reflect implementation of your BCCEDP in PY1 ONLY, July 1, 2012 – June 30, 2013.

WHAT DO WE MEAN BY ‘YOUR BCCEDP PROGRAM’? The term ‘BCCEDP program’ refers to all those involved in the implementation of the activity including you, your contractors, and your other partners.

WHAT DO WE MEAN BY ‘BCCEDP PROVIDERS’?

‘BCCEDP providers’ include all practitioners or contractors reimbursed (or otherwise funded as part of the program) for clinical services, including patient navigation/case management, through your BCCEDP program regardless of funding source (e.g., CDC funds, State funds, Komen funds).

WHAT DO WE MEAN BY ‘BCCEDP CLIENTS’?

‘BCCEDP clients’ include all persons who receive screening and/or patient navigation/case management through your BCCEDP program regardless of funding source (e.g., CDC funds, State funds, Komen funds).

WHAT DO WE MEAN BY ‘NON-BCCEDP’ PROVIDERS?

‘Non-BCCEDP providers’ include all practitioners who are not reimbursed for clinical services, including patient navigation/case management, through your BCCEDP program, but who receive some intervention (e.g., provider assessment and feedback) through your program.

WHAT DO WE MEAN BY ‘NON-BCCEDP’ CLIENTS?

‘Non-BCCEDP clients’ include all persons who do not receive screening and/or patient navigation/case management through your BCCEDP program, but who receive some other program intervention (e.g., group education) through your program.

WHAT DO WE MEAN BY ‘YOU AND YOUR BCCEDP STAFF’?

‘You and your BCCEDP staff’ include those people working within your organization (e.g., State health department, tribal program) that work with the BCCEDP program, regardless of funding source (e.g., CDC funds, State funds, Komen funds).

SECTION 1: RESPONDENT INFORMATION

1. With which BCCEDP program are you affiliated? [Dropdown list of all BCCEDP grantees]

• Check appropriate GRANTEE NAME

2. What is your current position with the BCCEDP program? (Check all that apply.)

• Program director (the primary contact for the BCCEDP cooperative agreement)

• Program manager/coordinator (the day-to-day manager for the BCCEDP)

• Other (please specify)

3. How long have you worked with the BCCEDP program in your state/tribe/territory/jurisdiction organization?

• < 1 year

• 1-2 years

• 3-5 years

• 6-10 years

• 11+ years

SECTION 2: PROGRAM ACTIVITIES

In the following sections, you will be asked questions about your implementation of specific program activities in program year 1 (PY1). Subsections A-C apply to provider-oriented activities; D-J address client-oriented activities.

1. PROVIDER REMINDERS

A provider reminder is used to inform a health care provider that a specific client is due or overdue for a cancer screening test. The reminder to a provider can be made in different ways such as in client charts, in client electronic medical records, or by e-mail.

1. In PY1, did your BCCEDP program use reminders for BCCEDP providers?

• Yes

• No

2. During PY1, did your BCCEDP program have a policy (written or unwritten) that requires or encourages all BCCEDP providers to use provider reminders?

• Yes

• No

• Not applicable, we instituted provider reminders directly with our providers

3. In PY1, did your BCCEDP program use reminders for non-BCCEDP providers?

• Yes

• No – skip to section 2.B

4. During PY1, what non-BCCEDP providers received provider reminders? (Check all that apply)

• Providers in Federally Qualified Health Centers or Community Health Centers

• Providers in the Indian Health Service or other tribal health organizations

• Providers in health care systems or associated with insurers (e.g., hospital, VA, Kaiser)

• Providers in individual offices or clinics, including local health department clinics

• Other (please specify):______________________

2. PROVIDER ASSESSMENT AND FEEDBACK

Provider assessment and feedback interventions evaluate provider performance (assessment) in delivering cancer screening to clients and then present providers with information (feedback) about their performance, sometimes comparing it with a goal or standard.

1. In PY1, did your BCCEDP program use clinical program data (e.g., MDEs) to produce provider or clinic-level feedback reports on some or all of CDC’s 11 core performance indicators (e.g., timeliness to diagnostic resolution, completeness) for BCCEDP providers?

• Yes

• No -- skip to section 2.B.3

2. During PY1, how frequently did your BCCEDP program distribute these feedback reports to BCCEDP providers or clinics?

• 1-2 times during PY1

• More than 2 times during PY1

3. In PY1, did your BCCEDP program use provider assessment and feedback activities for non-BCCEDP providers?

• Yes

• No – skip to section 2.C

4. During PY1, what non-BCCEDP providers received assessment and feedback reports? (Check all that apply)

• Providers in Federally Qualified Health Centers or Community Health Centers

• Providers in the Indian Health Service or other tribal health organizations

• Providers in health care systems or associated with insurers (e.g., hospital, VA, Kaiser)

• Providers in individual offices or clinics, including local health department clinics

• Other (please specify):______________________

3. PROFESSIONAL DEVELOPMENT/PROVIDER EDUCATION

Professional development and/or provider educational activities are designed to improve the knowledge, attitudes, cancer screening care, and counseling behaviors of healthcare providers and can be applied in a range of settings (e.g., pharmacies, physician offices, medical schools).

1. In PY1, did your BCCEDP program provide professional development/provider education (e.g., training sessions with CME credits, provider tool kits, academic detailing) for BCCEDP providers?

• Yes

• No

2. In PY1, did your BCCEDP program provide professional development/provider education (e.g., training sessions with CME credits, provider tool kits, academic detailing) for non-BCCEDP providers?

• Yes

• No –skip to section 2.D

3. During PY1, what non-BCCEDP providers received professional development/provider education? [Check all that apply]

• Providers in Federally Qualified Health Centers or Community Health Centers

• Providers in the Indian Health Service or other tribal health organizations

• Providers in health care systems or associated with insurers (e.g., hospital, VA, Kaiser)

• Providers in individual offices or clinics, including local health department clinics

• Other (please specify):______________________

4. CLIENT REMINDERS

Client (or patient) reminders are written, electronic or telephone messages advising people that they are due for cancer screening.

1. In PY1, did your BCCEDP program use client reminders for BCCEDP clients?

• Yes

• No

2. During PY1, did your BCCEDP program encourage BCCEDP providers to use client reminders?

• Yes

• No

• Not applicable, we send BCCECDP clients reminders directly

3. In PY1, did your BCCEDP program use client reminders for non-BCCEDP clients?

• Yes

• No – skip to section 2.E

4. During PY1, what non-BCCEDP clients received client reminders? (Check all that apply)

• Clients who receive healthcare through Federally Qualified Health Centers or Community Health Clinics

• Clients who receive healthcare through clinics of the Indian Health Service or other tribal health organizations

• Clients who receive healthcare through health care systems or insurers (e.g., hospital, VA, Kaiser)

• Clients who receive healthcare through individual physician offices/provider groups, including local health department clinics

• Enrollees of Medicaid/Medicare

• Other (please specify):________________________

5. SMALL MEDIA

Small media include videos and printed materials such as letters, brochures, and newsletters that can be used to inform and motivate people to be screened for cancer. Small media materials can provide information tailored to specific individuals or targeted to general audiences.

1. In PY1, did your BCCEDP program use small media (e.g., brochures, social media) with BCCEDP clients?

• Yes

• No

2. In PY1, did your BCCEDP program use small media (e.g., brochures, social media) with non-BCCEDP audiences?

• Yes

• No – skip to section 2.E.4

(If ‘no’ to both 1 and 2, skip to section 2.F)

3. During PY1, what non-BCCEDP audiences received small media materials? (Check all that apply)

• Clients who receive healthcare through Federally Qualified Health Centers or Community Health Clinics

• Clients who receive healthcare through clinics of the Indian Health Service or other tribal health organizations

• Clients who receive healthcare through health care systems or insurers (e.g., hospital, VA, Kaiser)

• Clients who receive healthcare through individual physician offices/provider groups, including local health department clinics

• Enrollees of Medicaid/Medicare

• Community members/the general public (e.g., religious organizations, workplaces, community-based organizations)

• Other (please specify):________________________

4. During PY1, did your BCCEDP program distribute small media materials in conjunction with any of the following activities? (Check all that apply)

• Patient navigation/case management (e.g., a navigator gives a patient an educational brochure in addition to addressing other barriers)

• Client reminders (e.g., a postcard sent to a client to remind them that they are due for screening also includes a general educational message about screening)

• One-on-one education (e.g., a health worker gives a brochure to a community member during outreach)

• Group education (e.g., a health educator distributes brochures as part of an educational session)

• We disseminate small media materials as a stand-alone intervention

6. MASS MEDIA

Mass media—including television, radio, newspapers, magazines, and billboards—are used to communicate educational and motivational information about cancer screening.

1. In PY1, did your BCCEDP program produce or support a mass media campaign?

• Yes

• No

7. REDUCING STRUCTURAL BARRIERS

Structural barriers are non-economic obstacles that make it difficult for people to access cancer screening (e.g., inconvenient hours or days of clinical service, transportation costs, unpaid sick leave). Interventions are designed to reduce these barriers in order to facilitate access to cancer screening services.

1. In PY1, did your BCCEDP program use activities to reduce structural barriers for BCCEDP clients?

• Yes

• No – skip to section 2.G.3

2. During PY1, what strategies did your BCCEDP program implement to reduce structural barriers for BCCEDP clients? (Check all that apply)

• Reducing time or distance between service delivery setting and priority populations

• Modifying hours of clinical service to better meet client needs

• Offering services in alternative or non-clinical settings (e.g., mobile mammography, sites with accommodations for those with disabilities)

• Eliminating or simplifying administrative procedures and other obstacles

• Providing clients assistance with transportation, language assistance, child/eldercare (e.g., patient navigation/case management)

• Other (please specify) ___________

3. In PY1, did your BCCEDP program implement activities to reduce structural barriers for non-BCCEDP clients?

• Yes

• No – skip to section 2.H

4. During PY1, what strategies did your BCCEDP program implement to reduce structural barriers for non-BCCEDP clients? (Check all that apply)

• Reducing time or distance between service delivery setting and priority populations

• Modifying hours of clinical service to better meet client needs

• Offering services in alternative or non-clinical settings (e.g., mobile mammography, sites with accommodations for those with disabilities)

• Eliminating or simplifying administrative procedures and other obstacles

• Providing clients assistance with transportation, language assistance, child/eldercare (e.g., patient navigation/case management)

• Other (please specify) ___________

8. COMMUNITY HEALTH WORKERS

Community health workers (CHWs) are lay health educators with a deep understanding of the community and are often from the community being served. CHWs work in community settings, in collaboration with a health promotion program, clinic, or hospital, to educate women about cancer screening, promote cancer screening, and provide peer support to women referred to cancer screening.

1. In PY1, did your BCCEDP program use Community Health Workers (CHWs)?

• Yes

• No – skip to section 2.I

2. During PY1, what activities were typically conducted by CHWs? (Check all that apply)

• Conduct outreach to community organizations/community members

• Conduct in-reach to contact women for re-screening

• Provide one-on-one education

• Provide group education

• Conduct peer counseling and support

• Connect women to a health care facility

• Refer or assist women with insurance enrollment (e.g., Medicaid/Medicare, private insurance, IHS, state-funded insurance)

• Assist women to address barriers to screening (e.g., transportation, language services)

• Other (please specify):_____________

3. In PY1, did your BCCEDP program provide training for CHWs? Note: we will ask about training for patient navigators and case managers separately, in the next section. (Check all that apply)

• Yes, our BCCEDP provided a structured CHW training program in PY1

• Yes, our BCCEDP paid for CHW training offered by others in PY1

• No

9. PATIENT NAVIGATION AND CASE MANAGEMENT

Patient navigators/case managers typically assist clients to overcome their individual barriers to cancer screening. Some BCCEDP programs use patient navigators/case managers to assist women through both cancer screening and diagnostic testing while other programs only use patient navigators/case managers to assist women through diagnostic testing, and if diagnosed with cancer, into cancer treatment.

The next set of questions asks about the use of patient navigators or case managers for cancer SCREENING. Questions about use of patient navigators/case managers for diagnostic testing will be asked later.

1. In PY1, did your BCCEDP program use patient navigators/case managers to assist BCCEDP clients through cancer SCREENING?

• Yes

• No

2. In PY1, did your BCCEDP use patient navigators/case managers to assist non-BCCEDP clients through cancer SCREENING?

• Yes

• No

[If No to both questions above, skip to section 2.I.4]

3. During PY1, what activities were typically delivered by patient navigators/case managers who assisted clients through cancer SCREENING? (Check all that apply)

• Assess client barriers to cancer screening

• Educate clients about screening test procedures

• Provide peer support/counseling

• Assist to schedule appointments for screening

• Arrange/provide transportation, translation (language), child or elder care services

• Make reminder calls for screening appointments

• Track/follow-up clients to ensure screening is complete and patient receives results

• Make recommendations to clinics/health systems on procedural or other changes that support client adherence to screening

• Collect and report data about navigator/case manager service delivery

• Other (please specify):_________________________________

The next set of questions asks about the use of patient navigators or case managers for DIAGNOSTIC TESTING.

4. In PY1, did your BCCEDP program use patient navigators/case managers to assist BCCEDP clients with abnormal screening results through DIAGNOSTIC TESTING?

• Yes

• No

5. During PY1, did your BCCEDP program use patient navigators/case managers to assist non-BCCEDP clients with abnormal screening results through DIAGNOSTIC TESTING?

• Yes

• No

[If No to both questions above, skip to section 2.I.7]

6. During PY1, what activities were typically delivered by patient navigators/case managers who assisted clients with abnormal screening results through DIAGNOSTIC TESTING? (Check all that apply)

• Assess client barriers to diagnostic testing

• Educate clients about diagnostic testing procedures

• Provide peer support/counseling

• Assist to schedule appointments for diagnostic testing

• Arrange/provide transportation, translation (language), child or elder care services

• Make reminder calls for diagnostic testing appointments

• Track/follow-up clients to ensure diagnostic testing is complete and patient receives results

• Assist clients diagnosed with cancer to get into cancer treatment

• Make recommendations to clinics/health systems on procedural or other changes that support client adherence to diagnostic testing

• Collect and report data about navigator/case manager service delivery

• Other (please specify):_________________________________

The next set of questions asks about training for patient navigators or case managers.

7. In PY1, did your BCCEDP program provide training about patient navigation/case management?

• Yes, our BCCEDP provided a structured PN/case management training program in PY1

• Yes, our BCCEDP paid for PN/case management training offered by others in PY1

• No - skip to section 2.J

8. What topics were addressed in the training? (Check all that apply)

• Assessing client barriers

• Screening guidelines for breast and cervical cancer

• Educating clients on breast and cervical cancer information

• Motivating clients to be screened

• Addressing structural barriers (e.g., transportation, language translation)

• Cultural competency

• Conducting patient tracking and follow-up

• Providing peer support/counseling

• Setting appropriate boundaries with clients

• Collecting/reporting data for patient navigation/case management

• Health systems change strategies

• Health reform issues

• Other (please specify):_________________

J. FACILITATING ENROLLMENT IN INSURANCE PROGRAMS FOR CANCER SCREENING

1. During PY1, did your BCCEDP program facilitate women’s enrollment in insurance coverage for breast and cervical cancer screening services (e.g., Medicaid, Medicare, IHS, state-based insurance)? This question is NOT referring to enrolling BCCEDP clients in Medicaid following a cancer diagnosis (commonly referred to as the “Treatment Act”).

• Yes

• No

SECTION 3: Clinical Service Delivery

The following questions apply specifically to delivering breast and cervical cancer screening and diagnostic clinical services to BCCEDP clients. Clinical services include patient navigation and case management.

A. Client eligibility criteria for screening

During PY1, please describe who was eligible to receive breast and cervical cancer clinical services in your BCCEDP program, based on your program’s general eligibility requirements, including Federal Poverty Level, insurance status, residency/citizenship/affiliation, and age.

1. During PY1, what Federal Poverty Level (FPL) was used to determine BCCEDP program eligibility for clients supported by CDC BCCEDP funds? (Check only one)

• 250% FPL

• 200% FPL

• Other (please specify): _____%

2. During PY1, did you require clients to provide any type of documentation (e.g., pay stubs) to determine eligibility based on FPL?

• Yes

• No

3. During PY1, what insurance status was used to determine BCCEDP program eligibility? (Check only one)

• Only uninsured women were eligible for BCCEDP services [skip to section 3.A.5]

• Both uninsured and under-insured women were eligible for BCCEDP services (i.e., under-insured are clients that are insured but cannot afford their insurance co-pay or deductible)

4. During PY1, did you track the number of women served by your BCCEDP program that were under-insured?

• Yes

• No

If yes, what percentage of the number of women served in PY1 were under-insured? ______

5. During PY1, what minimum age for routine screening was used to determine BCCEDP program eligibility? (Do not report exceptions for special circumstances, e.g. younger women if symptomatic, higher risk, or rarely/never screened):

Minimum age for clinical breast exam: ____

Minimum age for mammography screening: _____

Minimum age for Pap test: _____

Minimum age for HPV co-testing: _____

6. During PY1, was eligibility for the BCCEDP program restricted by any of the following requirements? (Check all that apply)

• Only U.S. citizens are eligible

• Only residents of our state or territory are eligible

• Only members or those with a defined affiliation with a tribe/tribal organization are eligible

• Other, please specify:__________________

• No, we do not use any of these requirements to restrict eligibility

7. During PY1, did you change your BCCEDP program eligibility criteria from a previous period? (Do not report on temporary changes needed to adjust screening budgets)

• Yes

• No - skip to section 3.B

8. Which BCCEDP program eligibility criteria were changed during PY1? (Check all that apply)

• Federal poverty level

• Insurance status

• Minimum age, clinical breast exam

• Minimum age, mammogram

• Minimum age, Pap test (excluding a change from age 18 to 21 per clinical guidelines)

• Minimum age for HPV co-testing

• Citizenship/residency/Tribal affiliation

• Other (please specify)____________

9. Why did your BCCEDP program change your program eligibility criteria in PY1? (Check all that apply)

• New clinical guidelines

• To reduce or narrow the number of women eligible for the program

• To expand the number of women eligible for the program

• Change in state/tribe/territory/jurisdiction regulation

• Implementation of health reform

• Other (please specify):__________________

B. BREAST AND CERVICAL CANCER PREVENTION AND TREATMENT ACT OF 2000

(Tribes and Territories will not be shown this section)

1. During PY1, did your State Medicaid program allow for clients diagnosed with cancer through your BCCEDP to enroll in Medicaid for their cancer treatment (commonly referred to as the “Treatment Act”)?

• Yes

• No

C. BCCEDP Clinic Service Reimbursement Model

1. During PY1, which payment reimbursement model best describes how your BCCEDP program paid for screening and diagnostic clinical services? (Check only one)

• Our organization provides clinical services directly (e.g., some tribal programs)

• Fee for service (Provider bills and is reimbursed for services/procedures performed; may be managed internally by the grantee or externally by contractor, third party payer, etc.)

• Capitated payment (A uniform reimbursement rate per woman served is established for a specified group of screening and/or diagnostic services.)

• Bundled payment (Reimbursement rates are established according to tiered case outcomes and are reimbursed retrospectively)

• Employed/Contracted Service Provider (Grantee uses BCCEDP funds to employ or contract with service providers for screening and/or diagnostic services; uses other vendor for cytology, radiology, etc.)

• Mixed (A combination of 2 or more of the above) or other payment model (please specify): _________________

D. BCCEDP PROVIDER SITES

1.    In the table below, please enter the number of individual primary care sites that delivered BCCEDP screening services in PY1 according to the type of provider setting. Please provide the number of sites or clinics, not the number of contracts. Do not include specialty clinics (e.g., imaging centers, labs).

	Number of BCCEDP sites/clinics that delivered BCCEDP screening services in PY1 If no sites of this type participated, enter ‘0’.   If this type of site participated, but you do not know the number of sites, enter ‘9999’.
Federally Qualified Health Centers or Community Health Centers
Indian Health Service or other tribal health organization sites or clinics
Individual offices or clinics, including local health departments, not including FQHCs
Health care systems, or clinics associated with an insurer (e.g. hospital, VA, Kaiser)
Other

SECTION 4: EVALUATION

1. During PY1, did your BCCEDP program conduct any evaluation of BCCEDP program activities? Please complete the table below by checking √ the appropriate response(s) for each activity.

Activity	Did not use	Used, but did not evaluate	Process Evaluation Collecting and analyzing information about how program activities were implemented, e.g., number of clients assessed by patient navigators	Outcome Evaluation Collecting and analyzing information about whether expected outcomes were achieved, e.g., changes in provider knowledge, client intentions, or screening rates
Provider reminders
Provider assessment & feedback
Professional development/Provider education
Patient or client reminders
Small media
Mass media
Reducing structural barriers
Community health worker activities
Patient navigation/case management
Training for patient navigation/case management
Other:

For the remainder of the data collection, the questions will focus on the staff members within your organization who work with the BCCEDP program.

SECTION 5: NON-SCREENING PARTNERSHIPS

1. During PY1, did you and your BCCEDP staff collaborate with any of the following agencies or types of organizations on BCCEDP-related program efforts, other than for direct screening services? (Check all that apply)

• Federally Qualified Health Centers (FQHC)

• Community Health Centers (Not FQHC)

• Hospitals, health systems or insurers in your state/area

• State Medicaid

• Medicare

• Indian Health Service (IHS) or other tribal organizations

• Local health departments

• Community-based nonprofit organizations (including faith-based)

• Employers/worksites in your state/area

• Accountable Care Organizations

• Cancer Coalition

• Other (please specify):__________________________

IF THE RESPONDENT SELECTED FQHC, MEDICAID, MEDICARE, IHS, OR ACCOUNTABLE CARE ORGANIZATIONS ABOVE, ASK THE FOLLOWING QUESTIONS FOR EACH:

2. Was the partnership formalized through a written agreement during PY1 (e.g., memoranda of understanding, memoranda of agreement, contract, grant)? Respond “yes” if you collaborated with one or more partners of this type and at least one partnership was formalized.

• Yes

• No

3. In general, what activities did you conduct with this type of partner during PY1? (Check all that apply)

• Implementing evidence-based screening promotion activities (i.e., small media, client reminders, provider reminders, removing structural barriers, provider assessment/feedback)

• Conducting CHW activities/patient navigation/case management

• Conducting mass media

• Conducting quality improvement/quality assurance activities (that are not an evidence based intervention)

• Conducting activities to improve the use of data (e.g., assess screening rates, measure screening quality)

• Facilitating insurance enrollment or 3^rd party funding

• Promoting organizational change (e.g., establishing absentee policy so that workers can take leave for screening appointments)

• Conducting worksite wellness programming

• Conducting special events (e.g. breast cancer awareness month activities)

• Conducting activities related to health reform

• Other (please specify): _____________________

SECTION 6: DATA USE

1. During PY1, did you and your BCCEDP staff use data (other than MDE data)? In the table below, for each data source that you and your BCCEDP staff used (e.g., BRFSS), please check the box or boxes that reflect how those data were used (e.g., measure screening rates). (Check all data uses that apply)

Data Source	Did not use in PY1	Measure screening rates	Measure clinical quality	Monitor and evaluate an activity	Assessment and planning
State Cancer Plan
BRFSS
State cancer registry or U.S. Cancer Statistics (USCS)
State or local screening registry
Census data (including Small Area Health Insurance Estimates)
IHS GPRA data (Government Performance and Results Act)
Medicaid data
Medicare data
Private insurer data (e.g., Kaiser, Blue Cross/Blue Shield)
All payor claims database
Patient records (e.g., within clinics or health systems, RPMS for tribal programs)
Primary data collection (e.g., pre-& post-tests, patient satisfaction survey)
Other (please specify):
Other (please specify):

2. During PY1, did you and your BCCEDP staff provide technical assistance to providers or staff of health systems to improve the use of their own data (e.g., assess screening rates, measure screening quality)? We are not referring to BCCEDP specific data (MDEs).

• Yes

• No – skip to section 7

3. During PY1, to what types of organizations did you and your BCCEDP staff provide this sort of technical assistance? (Check all that apply)

• Federally Qualified Health Centers or Community Health Centers

• Indian Health Service or other tribal health organizations

• Health care systems or insurers (e.g., Kaiser, VA, hospital)

• Individual offices or clinics, including local health department clinics

• Other (please specify):______________________

SECTION 7: TRAINING AND TECHNICAL ASSISTANCE

1. Using a scale of high to low, please rate the current need for training (not limited to PY1) among you and your BCCEDP staff in the areas listed below.

Area of Training/Technical Assistance	Level of Need for Training
	High	Medium	Low
Management activities
Program planning
Logic model development & use
Systems change
Program monitoring & evaluation
Data collection, management, & analysis
Program Activities (Evidence-based)
Provider reminders
Provider assessment & feedback
Client reminders
Small media
Reducing structural barriers
Program Activities (other)
Professional development/Provider education
Use of social media
Community health workers
Patient navigation/case management
Quality Assurance/Quality Improvement
Clinical guidelines for screening
Clinical guidelines for diagnostic evaluation
Quality assurance/quality improvement strategies
Other
Partnership development & maintenance
Health insurance exchanges/Marketplace
Medicaid expansion in your State
Health reform and covered preventive services
Other (please specify) _______________

Section 8: Program Management

1. Do you and your BCCEDP staff know the current size of the eligible BCCEDP population in your state/tribe/territory/jurisdiction?

• Yes

• No

2. Have you estimated the size of the eligible BCCEDP population in your state/tribe/territory/jurisdiction after health reform is implemented?

• Yes

• No

• N/A

3. What are the top 3 challenges that impacted the management of your BCCEDP program during PY1?

Management challenges	Check top 3
Staff furloughs/hiring freezes
Significant changes in administrative systems
Staff turnover
Loss of Federal funds (other than CDC NBCCEDP funds)
Loss of non-Federal funds
Loss of in-kind resources
Agency reorganization
Your state’s implementation of provisions of health reform
Changes in clinical guidelines for breast and cervical cancer (e.g., provider adherence to guidelines, data system changes)
Identifying women eligible for screening through the BCCEDP
Collaborating with state/tribal partners
Meeting CDC’s 60/40 requirement
Other (please specify)

4. Please list the amount of Federal, State, non-profit, and other funding that supported your BCCEDP program in PY1. Pro-rate funding if needed to associate with PY1.

Funding Source	Amount Received in PY1
Federal (Do not include funds received from CDC through the NBCCEDP DP12-1205-01 or through the PPHF DP12-1218)	$
State	$
Non-profit (e.g., ACS, Komen for the Cure, Livestrong)	$
Other - please specify:	$

The last 4 questions in this section are open-ended. We are asking about your experience to date (not limited to the time period of PY1).

5. Please list how you and your staff have participated in activities related to the Insurance Marketplace/exchange (e.g., attended training or meetings, participated on workgroups, where and if appropriate, discussed how you will coordinate benefits). If applicable, include information about how your BCCEDP is collaborating with the insurance navigators who are enrolling people into the insurance exchanges.   

6. If your state is expanding Medicaid as part of health reform, please list how you and your staff have participated in activities related to Medicaid expansion in your state (e.g., attended training or meetings, participated on workgroups or in policy discussions).

7. Please list any activities, procedures, or processes that your BCCEDP has established related specifically to BCCEDP clients and health reform (e.g., mailing materials to BCCEDP clients about the Insurance Marketplace, tracking BCCEDP clients transferred into Medicaid expansion, referring existing or potential BCCEDP clients to insurance navigators with the Insurance Marketplace, etc).  

8. Please list up to 3 main challenges you and your staff have faced related to health care reform and your BCCEDP program.

Public reporting burden of this collection of information is estimated to average 28 minutes per response, including the time for reviewing instructions 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 D­74, Atlanta, Georgia 30333; ATTN: PRA (09200879).