PRC Indicator Data Collection Web Survey

2013 PRC Indicator Data Collection

Web Survey

Note: The OMB expiration date will be assigned and included in the web survey upon OMB approval.

Part I: Collaboration with Health Departments and Number of Students Trained or Mentored (Year 4)

Introduction

Form Approved

OMB No. 0920-0650

Exp. Date: XX/XX/20XX

Welcome to Part I of the 2013 PRC Indicator Data Collection Web Survey. Data collected through this survey should reflect activities that occurred during Year 4 (September 30, 2012 - September 29, 2013) of the current 2010 - 2014 funding cycle. Your responses are essential to both document your accomplishments and describe the overall PRC Program.

Part I of the survey asks about 1) your PRC’s collaboration with health departments during Year 4 and 2) the number and academic level of students that were trained or mentored by your PRC faculty and staff during Year 4.

We appreciate the time needed to provide this important information.

Public reporting burden of this collection of information is estimated to average 5 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 (0920-0650).

Contact Information

PRC Institution Name (please select):

101 U of Alabama at Birmingham	115 Morehouse School of Medicine
102 U of Arizona	116 U of New Mexico
201 U of Arkansas for Medical Sciences	117 New York University School of Medicine
103 Boston U	118 U of North Carolina at Chapel Hill
104 U of California at Berkeley	205 Ohio State U
105 U of California at Los Angeles	119 Oregon Health & Science U
106 Case Western Reserve U	132 U of Pittsburgh
107 U of Colorado Denver	120 U of Rochester
108 Columbia U	121 St. Louis U and Washington U in St. Louis
202 Dartmouth College	122 San Diego State U (with U of California at San Diego
109 Emory U	123 U of South Carolina
110 Harvard U	124 U of South Florida
131 U of Iowa	125 Texas A&M Health Science Center
111 Johns Hopkins U	126 U of Texas Health Science Center at Houston
112 U of Kentucky	127 Tulane U
203 U of Maryland	128 U of Washington
204 U of Massachusetts Medical School	129 West Virginia U
113 U of Michigan	130 Yale U
114 U of Minnesota

Below, provide contact information for the person entering data

Name ____________________________________________

Email ____________________________________________

Phone Number (format 999-999-9999) ____________________________________________

Part I: Collaboration with Health Departments and Number of Students Trained or Mentored (Year 4)

Section 1: Collaboration with Health Departments

This section of the survey asks about your PRC’s collaboration with health departments or Indian Health Service/tribal agencies.

1. In Year 4 (September 30, 2012 – September 29, 2013), did your PRC faculty or staff members work with any state or city/county health departments or Indian Health Service/tribal agency in any of the following capacities?

• Technical assistance: Faculty or staff from the PRC provided expertise to the health department in areas such as grant writing, grant review, developing a health or educational campaign, developing a survey, etc.

• Evaluation: The PRC provided evaluation expertise or services to the health department. This could include the PRC being paid for evaluation services, or faculty or staff evaluating a specific intervention or program.

• Provision of resources: The PRC provided resources (staff, faculty, money, facilities) to the health department. This could include providing staff or volunteers for a particular project, supervising students during a practicum, providing space for a training, etc.

• Service on boards or committees: Faculty or staff from the PRC are a member of the health department board(s) or committee(s) OR staff from the health department are a member of the PRC's advisory board(s) or committee(s).

• Partnership for dissemination: The PRC and health department formed relationships to systematically disseminate an intervention or program.

	PRC provided technical assistance		PRC served on health department board(s) or committee(s)		PRC provided evaluation services		PRC provided resources		Health department staff served on PRC board(s) or committee(s)		Partnership for dissemination
	Yes	No	Yes	No	Yes	No	Yes	No	Yes	No	Yes	No
City or County Health Department
State Health Department
Indian Health Service or Tribal Agency

Part I: Collaboration with Health Departments and Number of Students Trained or Mentored (Year 4)

Section 2: Number of Students Trained or Mentored

This section asks about the number and academic level of students who were trained or mentored by your PRC faculty and staff during Year 4 (September 30, 2012 – September 29, 2013) of the 2010 – 2014 funding cycle. Students trained or mentored include all students that worked (paid or unpaid) with or for the PRC. The students must be connected to PRC activities through Core, SIP, or other projects within the scope of the PRC. This includes, but is not limited to, students who worked with the PRC through research assistantships, independent study, practica, internships, fellowships, or other activities.

NOTE: Exclude students who only attended academic classes taught by PRC faculty and exclude students who only attended formal PRC-developed or PRC-sponsored training programs.

2. For each academic level, indicate the total number of students trained or mentored during Year 4 (September 30, 2012 - September 29, 2013). If there were no students that received training or mentoring for a specified academic level, please enter zero for the number of students.

	Number of students trained or mentored by the PRC in Year 4
a. High school students
b. Undergraduate students
c. Masters’ students
d. Doctoral students
e. Post-doctoral students

Thank you

You have completed Part I of the web survey. Your response is very important to the PRC Program.

Part II: Newly Funded Other Research Projects (Year 4)

Introduction

Form Approved

OMB No. 0920-0650

Exp. Date: XX/XX/20XX

Welcome to Part II of the 2013 PRC Indicator Data Collection Web Survey. Data collected through this survey should reflect activities that occurred in Year 4 (September 30, 2012 - September 29, 2013) of the current 2010 - 2014 PRC Program funding cycle. Your responses are essential to both document your accomplishments and describe the overall PRC Program.

Part II of the survey collects data about "other funded research projects" (i.e., non-core, non-SIP research projects) that were newly funded and in progress during some or all of Year 4.

We appreciate the time needed to provide this important information.

Public reporting burden of this collection of information is estimated to average 5 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 (0920-0650).

Contact Information

PRC Institution Name (please select):

101 U of Alabama at Birmingham	115 Morehouse School of Medicine
102 U of Arizona	116 U of New Mexico
201 U of Arkansas for Medical Sciences	117 New York University School of Medicine
103 Boston U	118 U of North Carolina at Chapel Hill
104 U of California at Berkeley	205 Ohio State U
105 U of California at Los Angeles	119 Oregon Health & Science U
106 Case Western Reserve U	132 U of Pittsburgh
107 U of Colorado Denver	120 U of Rochester
108 Columbia U	121 St. Louis U and Washington U in St. Louis
202 Dartmouth College	122 San Diego State U (with U of California at San Diego
109 Emory U	123 U of South Carolina
110 Harvard U	124 U of South Florida
131 U of Iowa	125 Texas A&M Health Science Center
111 Johns Hopkins U	126 U of Texas Health Science Center at Houston
112 U of Kentucky	127 Tulane U
203 U of Maryland	128 U of Washington
204 U of Massachusetts Medical School	129 West Virginia U
113 U of Michigan	130 Yale U
114 U of Minnesota

Below, provide contact information for the person entering data

Name ____________________________________________

Email ____________________________________________

Phone Number (format 999-999-9999) ____________________________________________

Instructions

Please report "other funded research projects" that are new for Year 4 (i.e., were not submitted Years 1 - 3). For each new "other funded research project," provide the project's title; funding source(s), amount of funding for each source and if funding has ended; and health topic(s) addressed.

DEFINITIONS:
Other funded research project: An "other funded research project" is a research project for which PRC faculty or staff applied for and received funding from a foundation, government agency (e.g., NIH, CDC), or other funding source, for a defined project period. NOTE: Do not include your core project or SIPs. Only include "other" projects if they are funded research projects that are within the scope of your PRC's program of research.

Research project: The primary intent of a research project is to generate or contribute to generalizable knowledge whereby the new information has relevance beyond the population or program from which it was collected. Research projects examine the impact of risk and protective factors on health outcomes; determine the efficacy and effectiveness of strategies or programs to reduce disease and promote health; examine strategies for promoting the adaptation, translation and dissemination of effective programs. An evaluation project is considered research when the purpose of the evaluation is to test a new, modified, or previously untested intervention, service, or program to determine its effectiveness and the knowledge gained is applicable beyond the individual, specific program.

Non-research project: The primary intent of a non-research project is to provide a service or to improve a program or service. Intended benefits of the project are primarily or exclusively for the client(s) and/or a specific population they serve. Examples of non-research projects include providing technical assistance to health departments, training to community committees about prevention research methods and strategies, guidance to community coalitions regarding local policies, or other technical or tangible community services. An evaluation project is considered non-research when the purpose is to assess the success of an established program in achieving its objectives in a specific population and the information gained from the evaluation will be used to provide feedback to that program or the evaluation is used as a management tool to monitor and improve the program and has immediate benefit for the program or the clients receiving the services or interventions. The information is often not generalizable beyond the individual program.

Note: The following questions only ask about new "other funded research projects". Do not include or report on those "other funded research projects" that were submitted in Years 1, 2, or 3.

How many “other funded research projects” that were new in Year 4 (September 30, 2012 – September 29, 2013) does your PRC have to report? If your PRC does not have new “other funded research projects to report, please enter zero. ____

Thinking about a specific "other funded research project", please answer the following questions

1. What is the title of the project?

____________________________________________

2) What are the funding source(s) and direct dollar amount(s) received for this "other funded research project" received during Year 4 (September 30, 2012 - September 29, 2013). A funding source is a foundation, government agency, or other funding agency which is providing funding for this project.

Note: If funding source is CDC or NIH, please specify the center, division, or institute as applicable.

	Funding Source	Amount of direct funding received in Year 4
Funding source 1
Funding source 2
Funding source 3
Funding source 4
Funding source 5

3) Did all funding end for this project during Year 4 (September 30, 2012 - September 29, 2013)?

( ) Yes

( ) No

4) Which health topic(s) does this "other funded research project” address? (Check all that apply)

[ ] Cancer

[ ] Diabetes

[ ] HIV/AIDS and STD Prevention

[ ] Heart disease or stroke

[ ] Injury and violence

[ ] Mental health

[ ] Nutrition

[ ] Obesity and overweight

[ ] Physical activity

[ ] Respiratory disease

[ ] Substance and/or alcohol use and/or abuse

[ ] Teen pregnancy prevention

[ ] Tobacco prevention and control

[ ] Other (please specify)

[ ] This study does not focus on a specific health topic

This completes the data needed for this "other funded research project". Click "Next" to enter data for your next project or to review your responses.

Thank you

You have completed Part II of the web survey. Your responses are important to the PRC Program.

Part III: Formal Training Programs (Year 4)

Introduction

Form Approved

OMB No. 0920-0650

Exp. Date: XX/XX/20XX

Welcome to Part III of the 2013 PRC Indicator Data Collection Web Survey. Data collected through this survey should reflect activities that occurred during Year 4 (September 30, 2012 - September 29, 2013) of the current 2010 - 2014 funding cycle.

Part III of the survey asks about the number of formal training programs your PRC implemented during Year 4. Your responses are essential to both document your accomplishments and describe the overall PRC Program. We will also use information collected about formal training programs to update the PRC Program's Training Catalog located on the program's website. Please keep this in mind as you complete the questions.

We appreciate the time needed to provide this important information.

Public reporting burden of this collection of information is estimated to average 5 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 (0920-0650).

Contact Information

PRC Institution Name (please select):

101 U of Alabama at Birmingham	115 Morehouse School of Medicine
102 U of Arizona	116 U of New Mexico
201 U of Arkansas for Medical Sciences	117 New York University of School of Medicine
103 Boston U	118 U of North Carolina at Chapel Hill
104 U of California at Berkeley	205 Ohio State U
105 U of California at Los Angeles	119 Oregon Health & Science U
106 Case Western Reserve U	132 U of Pittsburgh
107 U of Colorado Denver	120 U of Rochester
108 Columbia U	121 St. Louis U and Washington U in St. Louis
202 Dartmouth College	122 San Diego State U
109 Emory U	123 U of South Carolina
110 Harvard U	124 U of South Florida
131 U of Iowa	125 Texas A&M Health Science Center
111 Johns Hopkins U	126 U of Texas Health Science Center at Houston
112 U of Kentucky	127 Tulane U
203 U of Maryland	128 U of Washington
204 U of Massachusetts Medical School	129 West Virginia U
113 U of Michigan	130 Yale U
114 U of Minnesota

Below, provide contact information for the person entering data

Name ____________________________________________

Email ____________________________________________

Phone Number (format 999-999-9999) ____________________________________________

Instructions

We define a formal training program as one that your PRC funds or administers, and is replicable and portable (i.e., has fixed content that can be transferred to a different audience or population). The program may occur once, be recurring, or be available for ongoing distribution through your PRC. Most PRC formal training programs confer a new skill set or new knowledge.

Formal training programs do NOT include:

• Courses offered for university credit

• Training programs related to a specific research project (e.g., teaching interviewers to execute a particular survey protocol or orienting staff to a particular PRC project)

• Conferences or conference presentations that are for information sharing (NOTE: you may include a training program that is embedded in a conference setting or a conference that is specifically conducted to provide training via workshops)

• A fellowship or internship program

• A series of presentations (e.g., guest lectures on changing topics, a journal club, a brown bag series, etc.)

• An individual presentation

How many different formal training programs (i.e., programs with different content) did the PRC deliver or implement during Year 4 (September 30, 2012 – September 29, 2013)? If your PRC did not deliver or implement any formal training programs in Year 4, please enter zero.

Note: This question asks about the number of different formal training programs, not how many times your PRC repeated the same training.

____

Thinking about a specific formal training program, please answer the following questions:

1. What is the title of the formal training program?

2. How many people received the training, by audience type? (Please enter zero for audience types that received no training for the specific program. If a trainee fits in more than one category, please select the one category representing the affiliation that most likely brought the trainee to the training)

	Total # of people trained in Year 4
Academic faculty or other researcher
Community member
Community agency or other non-governmental organization representative
Health care practitioner
Public health employee
Public health student
Other

3. Please provide a brief description (≤300 words) of the formal training program that we could include in the training catalog on the PRC Program website. The description at a minimum should include: 1) content addressed; 2) what skills or knowledge are conveyed; 3) training duration (e.g., 2 hours a day for 4 days or 3-8 hours); 4) training format (e.g., web-based, classroom); and 5) intended audiences.

This completes the information needed for this formal training program. Click "Next" to enter information for your next formal training program or to review your responses.

Thank you

You have completed Part III of the web survey. Your responses are important to the PRC Program.

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