Telephone Interview

Form Approved

OMB No. 0920-0650

Exp. Date xx/xx/xxxx

Telephone Interview – 2013 Indicator Data Collection

Public reporting burden of this collection of information is estimated to average 30 minutes 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: OMB 0920-0650

Identification Information

Interviewer:      

Name of PRC: Enter institution name PRC ID ###

Date interview conducted: mm/dd/yyyy

Name of PRC person participating in interview: Enter name

Introduction:

The purpose of the telephone interview is to understand your PRC’s contribution to systems and environmental changes and the identifiable action your PRC took in bringing about the change.

Systems and Environmental Changes

The questions below pertain to your PRC’s contributions towards systems and environmental change.

• Systems changes affect populations and can occur as a result of any law, rule, regulation (formal or informal), or a standard practice.

  • Systems changes must be sustainable— (e.g., a school-based intervention funded by a grant continues to be offered after the study is over).

    • An example of a non-sustainable change: PRC is funded to evaluate an intervention. Schools offer the intervention during the study period but do not make it a formal part of their curriculum.

Remember: PRCs are NOT allowed to use any federal dollars for lobbying.

Restricted activities include:

• Encouraging calls to legislators

• Public calls to action

• Advocacy for increased funding

• Advocating for specific laws

• Recommending law or policy

Note: While it is permissible for an elected official to request you or your PRC as a subject matter expert (SME), the elected official cannot tell you how to testify/educate. If an elected official did not request a PRC as a SME, the PRC is not allowed to use federal dollars to offer SME services.

For further information please visit: http://www.cdc.gov/od/pgo/funding/grants/foamain.shtm

• Environment refers to the physical (built environment), social (social context or social structures), and economic (access to employment, income, wealth, and other resources that influence consumerism) environments.

  • Environmental changes include building walking trails in a community, making low-fat choices available in cafeterias, or removing ashtrays from break rooms, etc.

1. During Year 4 of the 2010 – 2014 funding cycle (September 30, 2012 – September 29, 2013), did your PRC contribute to the creation or alteration of any systems or environmental changes to promote health or prevent disease?
   Yes

No  You do not need to schedule an interview. Please email Elizabeth Neri ([email protected]) and let her know that you do not have any systems or environmental changes to report in year 4.

2. How many changes do you have to report? _________

For each change, please provide the following information:

1. Briefly describe the change. When describing a systems change that involves the passage of a bill or law, please provide the bill number and date it was passed. Please provide any supporting information that highlights the change (e.g. website or news article).

2. PRCs can play various roles in systems and environmental changes and these roles maybe formal or informal. Please describe the identifiable action your PRC took to bring about the change. Briefly describe what the PRC did and for whom.

3. Was the change associated with a core, SIP, other project, or PRC-related activity?

Core
SIP
Other

PRC-related activity

4. What was the name of the project?

5. If the project was Core or SIP, from which funding cycle was the project?

2010 – 2014
2005 – 2009
Before 2004

***If there is another change, repeat questions 2a – e. If there are no more systems or environmental changes this ends the interview. Thank you for your participation.

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