Form SS Local Health Department Capacity and Readiness

Form Approved

OMB No. 0920-XXXX

Exp. Date:

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Attachment SS:

Local Health Department Capacity and Readiness

Dating Matters: Strategies to Promote Healthy Teen Relationships™ Initiative

Division of Violence Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Site Number: _________________________, Survey Date: ________________________________

Program Year: _________________________ Survey Iteration: ___________________________

Dating Matters Capacity Assessment: Local Health Departments Survey

(Introduction text to be added)

1. How long have you worked at your local health department? Please enter the number of years and/or months.

   Years

   Months

2. What is your primary role within your local health department? Select one answer.

₁ Administrator (e.g., program manager or director)

₂ Clinician (e.g., nurse, physician)

₃ Administrative support

₄ Health or Outreach Educator

₅ Counselor/Social Worker

₆ Youth Program or Prevention Program Specialist

₇ Other, please specify _________________________

3. How long have you worked with prevention programs (of any type) for youth at your local health department? Please enter the number of years and/or months.

   Years

   Months

4. Outside of your local health department, how long have you worked with prevention programs (of any type) for youth? Please enter the number of years and/or months.

Years

Months

DATING MATTERS LEVEL

First, we have some questions about the Dating Matters initiative. This initiative specific information will aid in identifying both strengths and challenges with your capacity to implement evidence based programming as a part of this initiative. Your information along with other stakeholders completing the survey will allow for a productive action planning process to address capacity challenges. Let’s start at the initiative level.

Staffing

5. How much do you agree or disagree with each of the following statements about the Dating Matters initiative? Select one answer per row.

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Don’t Know
Staff time allocated for the Dating Matters initiative is protected (i.e., staff members are not pulled away to do other work).	1	2	3	4	5	0
There are enough local health department staff members to implement the Dating Matters initiative.	1	2	3	4	5	0
Staff turnover at the local health department may interfere with implementing the Dating Matters initiative.	5	4	3	2	1	0
Our organization has the fiscal resources it needs to implement the Dating Matters initiative.	1	2	3	4	5	0
Staff members have skills in developing prevention programs that reflect the needs of the population.	1	2	3	4	5	0

Scoring: mean of items a–e with b reverse coded.

Organizational Cohesion

6. Programs like the Dating Matters initiative sometimes experience organizational challenges. How much do you agree or disagree with each of the following statements? Please consider both the core Dating Matters program staff, as well as support staff (e.g., IT, accounting, clerical). Select one answer per row.

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Don’t Know
a. Staff working on the Dating Matters initiative get along well.	1	2	3	4	5	0
b. There is much friction among the staff working on the Dating Matters initiative.	5	4	3	2	1	0
c. Staff working on the Dating Matters initiative work together as a team.	1	2	3	4	5	0
d. Staff working on the Dating Matters initiative are quick to help one another when needed.	1	2	3	4	5	0
e. Staff working on the Dating Matters initiative ask one another for help when needed.	1	2	3	4	5	0
f. Mutual trust and cooperation are strong among the staff working on the Dating Matters initiative.	1	2	3	4	5	0
g. Some staff working on the Dating Matters initiative do not do their share of the work.	5	4	3	2	1	0
h. Staff understand their role in implementing the Dating Matters initiative.	1	2	3	4	5	0

Scoring: Organizational Cohesion Scale: mean of items a–h with 2 items reverse coded.

DIVISION LEVEL

Next, we have some questions about the division or unit where Dating Matters is located within your local health department.

Organizational Structure and Function

7. How much do you agree or disagree with each of the following statements about the division where Dating Matters is located? Select one answer per row.

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Don’t Know
a. Staff know how their own jobs relate to the overall mission of the division.	1	2	3	4	5	0
b. The work standards expected of people are clear.	1	2	3	4	5	0
c. Staff get well-defined feedback about how well they are doing.	1	2	3	4	5	0
d. Staff participate in other parts of the division, enough to be able to appreciate their role in that wider environment.	1	2	3	4	5	0
e. Staff can take part in the decisions that affect them.	1	2	3	4	5	0
f. The division uses an effective procedure for resolving conflicts.	1	2	3	4	5	0

Scoring: Organizational Learning Scale: mean of items a–f. Report “disagree” responses in action plan.

Knowledge about Teen Dating Violence Prevention

8. Staff members often vary in their knowledge about teen dating violence prevention. How much do you agree or disagree with each of the following statements? Please think about the division in which Dating Matters is located.

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Don’t Know
a. Staff are knowledgeable about teen dating violence.	1	2	3	4	5	0
b. Staff are knowledgeable about evidence-based teen dating violence prevention programs.	1	2	3	4	5	0
c. Staff are experienced in overseeing community-based prevention efforts.	1	2	3	4	5	0
d. Staff are experienced in overseeing school-based prevention efforts.	1	2	3	4	5	0
e. Staff are encouraged to attend training specific to teen dating violence prevention.	1	2	3	4	5	0
f. Staff have the necessary skills to support the Dating Matters initiative.	1	2	3	4	5	0
g. Staff have experience obtaining IRB approval for collecting evaluation data.	1	2	3	4	5	0

Scoring: mean of items a–f. Report “disagree” responses in action plan.

Capacity to Support Evaluation Activities

9. How much do you agree or disagree with each of the following statements? Select one answer per row.

My division has staff who can…

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Don’t Know
a. Explain the benefits of evaluation to schools.	1	2	3	4	5	0
b. Effectively overcome barriers to evaluation participation in schools.	1	2	3	4	5	0
c. Effectively overcome barriers to evaluation participation in the local health department .	1	2	3	4	5	0
d. Work with an evaluator to develop procedures for collecting evaluation data from parents and/or youths.	1	2	3	4	5	0
e. Work with an evaluator to develop procedures for collecting implementation data from program staff.	1	2	3	4	5	0
f. Work with an evaluator to interpret evaluation findings for the Dating Matters initiative.	1	2	3	4	5	0
g. Disseminate findings from the evaluation of the Dating Matters program.	1	2	3	4	5	0

Scoring: mean of items a–g. Report “disagree” responses in action plan.

Readiness: Needs Assessment

10. In the past 12 months, has your division done any of the following to prepare for the Dating Matters initiative? Select one answer per row.

	Yes	No	Don’t Know
a. Collected or compiled data on the prevalence of teen dating violence in your community.	1	0	2
b. Collected or compiled data on risk and protective factors related to teen dating violence in your community.	1	0	2
c. Collected or compiled data on teen dating violence-related intervention outcomes in your community.	1	0	2
d. Added or recommended adding questions about teen dating violence to surveillance surveys	1	0	2

Scoring: means of items a–d. Report “no” responses in action plan.

Readiness: Strategic Planning

11. In the past 12 months, has your division done any of the following to prepare for the Dating Matters initiative? Select one answer per row.

	Yes	No	Don’t Know
Included dating violence prevention in the strategic plan.	1	0	2
b. Included the Dating Matters initiative specifically in the strategic plan.	1	0	2
c. Assessed the fit between the Dating Matters initiative requirements and staff skills.	1	0	2
d. Assessed whether the Dating Matters intervention options overlap with programs that already exist in the community.	1	0	2
e. Developed a communication plan to keep internal and external stakeholders informed on the Dating Matters initiative.	1	0	2

Scoring: means of items a–e. Report “no” responses in action plan.

LOCAL HEALTH DEPARTMENT LEVEL

The next set of questions is about your local health department. Please think about your entire local health department, even divisions unrelated to Dating Matters.

Organizational Climate for Innovation

12. How much do you agree or disagree with each of the following statements about your local health department? Select one answer per row.

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Don’t Know
a. The local health department has a history of participating in innovative public health initiatives.	1	2	3	4	5	0
b. Within the local health department, ideas for new approaches are welcomed.	1	2	3	4	5	0
c. Staff are encouraged to try new things within the local health department.	1	2	3	4	5	0
d. The local health department has a flexible structure to allow for new processes to be adopted.	1	2	3	4	5	0

Scoring: mean of items a–d. Report as a single item.

Leader Consensus Building and Conflict Management

13. How much do you agree or disagree with the following statements? Select one answer per row.

Your local health department leadership is…

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Don’t Know
a. Able to build consensus within the local health department.	1	2	3	4	5	0
b. Willing to involve other health department staff members in decision making.	1	2	3	4	5	0
c. Able to manage conflict within the local health department.	1	2	3	4	5	0

Scoring: Community Leader Scale: mean of items a–c.

Effective Local Health Department Leadership

14. How much do you agree or disagree with the following statements about your local health department as a whole? Select one answer per row.

Your local health department leadership is…

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Don’t Know
a. Knowledgeable about teen dating violence prevention.	1	2	3	4	5	0
b. Committed to preventing teen dating violence.	1	2	3	4	5	0
c. Able to obtain the necessary financial resources for teen dating violence prevention initiatives.	1	2	3	4	5	0
d. A strong advocate for the Dating Matters initiative.	1	2	3	4	5	0
e. Motivated to ensure that the Dating Matters initiative is a success.	1	2	3	4	5	0
f. Knowledgeable about the extent of other teen dating violence efforts in the community.	1	2	3	4	5	0
g. Supportive of staff implementing the Dating Matters initiative.	1	2	3	4	5	0

Scoring: Community Leaders as Prevention Advocates Scale: mean of items a–g.

Clear Vision/Mission

15. How much do you agree or disagree with each of the following statements about your local health department? Select one answer per row.

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Don’t Know
a. The Dating Matters initiative is consistent with our local health department’s mission.	1	2	3	4	5	0
b. There is a common vision in the health department about the methods needed for preventing teen dating violence.	1	2	3	4	5	0
c. Most staff members see using evidence-based approaches as an essential part of our health department’s work.	1	2	3	4	5	0

Scoring: mean of items a–c.

Teen Dating Violence Prevention History

16. In the past 12 months, has your local health department done any of the following? Select one answer per row.

	Yes	No	Don’t Know
a. Supported a teen dating violence prevention curriculum with adolescents.	1	0	2
b. Supported a teen dating violence prevention curriculum with parents or families.	1	0	2
c. Adapted a teen dating violence prevention curriculum to better address the needs of your community.	1	0	2
d. Supported or coordinated training for a teen dating violence prevention curriculum.	1	0	2
e. Facilitated or participated in youth-led efforts to prevent teen dating violence.	1	0	2
f. Identified gaps in local policy related to teen dating violence prevention.	1	0	2
g. Supported the development and enhancement of policy related to teen dating violence prevention.	1	0	2
h. Convened an advisory group to address teen dating violence prevention.	1	0	2
Used media, including but not limited to print, online, and social media, for teen dating violence prevention.	1	0	2

Scoring: mean of items a–i. Report “no” responses in action plan.

Linkages with Community-Based Organizations

17. How much do you agree or disagree with each of the following statements about your local health department’s relationship with community-based organizations? Select one answer per row.

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Don’t Know
a. The local health department is part of a network of organizations committed to preventing teen dating violence.	1	2	3	4	5	0
b. The local health department shares ideas or information about teen dating violence prevention with community-based organizations.	1	2	3	4	5	0
c. The local health department and community-based organizations have managed to work together in spite of differences that may arise between them.	1	2	3	4	5	0

Scoring: mean of items a–c.

Partnerships with Other Government Agencies

18. How much do you agree or disagree with each of the following statements about your local health department’s relationship with other government agencies? Select one answer per row.

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Don’t Know
a. The local health department and other government agencies coordinate with each other on violence prevention efforts.	1	2	3	4	5	0
b. The local health department shares ideas or information about teen dating violence prevention with other government agencies.	1	2	3	4	5	0
c. The local health department and other government agencies have managed to work together in spite of differences that may arise between them.	1	2	3	4	5	0

Scoring: mean of items a–c.

Collaboration

19. In the past 12 months, how much has your local health department collaborated with the following organizations? Select one answer per row.

	Not at All	A Little	Some	A Lot	Don’t Know
a. K-12 Schools.	1	2	3	4	0
Colleges and/or Universities.	1	2	3	4	0
b. Youth serving organizations (e.g., Boys and Girls Clubs, Big Brothers/Big Sisters, Scouts)	1	2	3	4	0
c. Local domestic violence agencies.	1	2	3	4	0
d. Batterer intervention programs.	1	2	3	4	0
e. Police or juvenile justice department.	1	2	3	4	0
f. Faith community.	1	2	3	4	0
g. Local substance abuse organizations.	1	2	3	4	0
h. Local recreation department.	1	2	3	4	0
i. Other local public health or social service departments.	1	2	3	4	0
j. State public health or social service departments.	1	2	3	4	0
k. Private social service agencies.	1	2	3	4	0
l. Business community.	1	2	3	4	0
m. Courts or judicial system.	1	2	3	4	0
n. Other health care agencies (e.g., hospitals, doctors’ offices, clinics).	1	2	3	4	0
o. Citizen groups or service organizations (e.g. crime watch groups, Kiwanis, Rotary, or Lions clubs).	1	2	3	4	0
p. Other, please specify _______________________________	1	2	3	4	0

Scoring: recode “not at all” = 0; and remaining responses = 1. Sum scores of 1. Report “not at all” responses in action plan.

20. Describe any challenges in collaborating with other organizations (e.g., schools or community-based organizations) on teen dating violence issues in the past 12 months.

[Include open-ended comment box]

21. Describe the strengths of your local health department’s collaborative efforts in the past 12 months.

[Include open-ended comment box]

Political Influence of Leaders

22. Please consider the leadership in your local health department. How much do you agree or disagree with each of the following statements? Select one answer per row.

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Don’t Know
a. Local health department leaders can gain support from elected or appointed officials when needed.	1	2	3	4	5	0
b. Local health department leaders can influence laws and policies that could prevent teen dating violence.	1	2	3	4	5	0
c. Elected or appointed officials are aware of the Dating Matters initiative.	1	2	3	4	5	0

Scoring: mean of items a–c.

Advocacy for Prevention Policy

23. In the past 12 months, has someone from your local health department done any of the following? Select one answer per row.

	Yes	No	Don’t Know
a. Advocated for more resources or opportunities for teen dating violence prevention within your health department.	1	0	2
b. Advocated for more resources or opportunities for teen dating violence prevention outside of your health department.	1	0	2
c. Advocated to influence policies to promote teen dating violence prevention.	1	0	2
d. Educated legislators on the need for teen violence prevention efforts.	1	0	2

Scoring: mean of items a–d.

Violence Prevention Policy Activities

23. In the past 2 years, has your local health department worked on any of the following? Select one answer per row.

a. Conducted an inventory of existing policies related to violence prevention …

Yes No Don’t Know

On the school district level _{1 0 2}

On the local level _{1 0 2}

On the state level _{1 0 2}

b. Identified gaps in existing policies related to violence prevention …

Yes No Don’t Know

On the school district level _{1 0 2}

On the local level _{1 0 2}

On the state level _{1 0 2}

c. Supported the development or enhancement of policies related to violence prevention …

Yes No Don’t Know

On the school district level _{1 0 2}

On the local level _{1 0 2}

On the state level _{1 0 2}

d. Implemented or supported the implementation of policies related to violence prevention …

Yes No Don’t Know

On the school district level _{1 0 2}

On the local level _{1 0 2}

On the state level _{1 0 2}

Strong State Leadership

23. How much do you agree or disagree with each of the following statements about state public health leaders? Select one answer per row.

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Don’t Know
a. State public health leaders exhibit strong and sustained commitment to teen dating violence prevention.	1	2	3	4	5	0
b. There is a common vision for teen dating violence prevention among the state public health leadership.	1	2	3	4	5	0
c. The state public health department has strong leadership advocating for teen dating violence prevention.	1	2	3	4	5	0

Scoring: mean of items a–c.

Staffing

23. Of all the employees in your local health department, how many work on violence prevention efforts ….

Full-time

Part-time

₀ Don’t Know

23. Including contracted staff, how many employees currently work on the Dating Matters initiative?

Full-time

Part-time

₀ Don’t Know

Integrated Data Systems

23. Which of the following statements apply to your local health department, if any? Select one answer per row.

	Yes	No	Don’t Know
The local health department has sufficient local data on the prevalence of teen dating violence.	1	0	2
Our local health department’s data system is linked with other relevant government agencies.	1	0	2
There is a systematic approach to gathering data on the prevalence of dating violence across local agencies.	1	0	2
d. Data are routinely shared across the public health system.	1	0	2

Scoring: mean of items a–d.

Funding

23. In the past fiscal year, has your local health department applied for violence prevention funds from resources other than the Dating Matters initiative? Select one answer.

₁ Yes  Go to Question 30

₂ No  Go to Question 31

₃ Don’t Know  Go to Question 31

23. In the past fiscal year, has your local health department received funding for violence prevention from sources other than the Dating Matters initiative? Select one answer.

₁ Yes

₂ No

₃ Don’t Know

If yes, please specify.

Sustainability

23. How much do you agree or disagree with each of the following statements? Select one answer per row.

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Don’t Know
Other violence prevention efforts supported by the local health department have demonstrated sustainability.	1	2	3	4	5	0
The local health department includes violence prevention efforts in the annual budget.	1	2	3	4	5	0
The local health department has at least one staff position devoted to violence prevention efforts.	1	2	3	4	5	0
Violence prevention is integrated with other health-related prevention programs.	1	2	3	4	5	0
The local health department is planning for sustainability of Dating Matters.	1	2	3	4	5	0
The local health department is looking for other funding resources to support Dating Matters when the grant ends.	1	2	3	4	5	0
The local health department is committed to the long-term goals of Dating Matters.	1	2	3	4	5	0
Dating Matters is part of a long-term collaborative effort with other agencies to prevent violence.	1	2	3	4	5	0
Dating Matters is unlikely to be sustained when the grant ends .	5	4	3	2	1	0
The local health department has multiple funding sources for violence prevention.	1	2	3	4	5	0

Scoring: mean of items a-j.

23. What factors may hinder sustaining Dating Matters when the grant ends?

[Include open-ended comment box]

23. What factors may support sustaining Dating Matters when the grant ends?

[Include open-ended comment box]

Cost Estimates

23. What is the total value of student participation incentives sent to schools over the past 12 months?

23. What is your annual salary?

$0 to $9,999

$10,000 to $19,999

$20,000 to $29,999

$30,000 to $39,999

$40,000 to $49,999

$50,000 to $59,999

$60,000 to $69,999

$70,000 to $79,999

$80,000 to $89,999

$90,000 to $99,999

$100,000 or above

23. How much time (excluding travel time) did you spend on Dating Matters over the past 12 months?

23. How much travel time and mileage did you spend on Dating Matters over the past 12 months?

23. What is the total value of parent participation incentives distributed over the past 12 months?

23. What is the total value of facilitator stipends distributed over the past 12 months?

23. What is the total postage of mailing “Adapted Families for Safe Dates” to parents of 8^th grade students over the past 12 months?

23. What is the total cost of facilities and equipment for Dating Matters over the past 12 months?

23. What is the total cost of office supplies and software for Dating Matters over the past 12 months?

23. What is the student curricular master trainer’s annual salary?

$0 to $9,999

$10,000 to $19,999

$20,000 to $29,999

$30,000 to $39,999

$40,000 to $49,999

$50,000 to $59,999

$60,000 to $69,999

$70,000 to $79,999

$80,000 to $89,999

$90,000 to $99,999

$100,000 or above

23. What is the cost of recruiting parent program managers and master trainers?

23. What is the cost of recruiting key staff?

23. How much time did you spend on the curricula adaptation in the planning year?