AIRS Data Collection Instrument (Word) 20130423

Data Requirements

44

Form Approved

OMB No. 0920-0853

Exp. Date xx/xx/20xx

Attachment 4

AIRS Data Collection Instrument

Public Reporting Burden Statement

Public reporting burden of this collection of information is estimated to average 4 hours for the interim report and 4 hours for the end of year report, 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; ATTN: PRA 0920-0853.

Overview

The Air Pollution and Respiratory Health Branch (APRHB) of the National Center for Environmental Health (NCEH), leads Centers for Disease Control and Prevention’s (CDC) fight against environmental-related respiratory illnesses, including asthma, and studies indoor and outdoor air pollution. APRHB seeks to implement a management information system (MIS). The MIS will be known as the “Asthma Information Reporting System” (AIRS) and will be intended to allow APRHB’s grantees to document information relevant to their programs including resources, work plan and indicators.

Purpose

The purpose of this document is to define the data requirements for AIRS.

Program Summary

Contact Information

Question Asked	Response Option
Grantee Name*	Enter text (100 characters/20 words) Pre-populate with initial data
Award Number*	Enter text (20 characters) Pre-populate with initial data
Announcement Number*	Enter text (20 characters) Pre-populate with initial data
Funded Components*	Select all that apply: Core Component Expanded Components Surveillance Partnership Intervention I Default to “Core Component” Pre-populate with initial data
Program Mailing Address*	Address Line 1 Address Line 2 City, State, Zip
Program Shipping Address*	Is this same as Program Mailing Address – Yes/No Address Line 1 Address Line 2 City, State, Zip
FAX*	Enter number
State Program Website*	Enter text (100 characters/20 words) Allow “Not applicable”
Other Asthma Program Website	Enter text (100 characters/20 words)

*Required information

Program Summary

Question Asked	Response Option
Surveillance Abstract*	Enter text (2000 characters/400 words)
Partnerships Abstract*	Enter text (2000 characters/400 words)
Intervention Abstract*	Enter text (2000 characters/400 words)
Evaluation Abstract*	Enter text (2000 characters/400 words)
Success Story*	Upload file (format = MS Word, PDF) Allow more than one story to be uploaded One is required; additional are optional
Description of Problem*	Enter text (1000 characters/200 words)
Segments of Population Disproportionately Affected*	Enter text (1000 characters/200 words)
Describe Unmet Needs and Strategies to Address Needs*	Enter text (1000 characters/200 words)
Expanded Surveillance Abstract	Enter text (2000 characters/400 words) Display and require if Expanded Component is selected in Contact Information
Expanded Partnership Abstract	Enter text (2000 characters/400 words) Display and require if Expanded Component is selected in Contact Information
Expanded Intervention Abstract	Enter text (2000 characters/400 words) Display and require if Expanded Component is selected in Contact Information

*Required information

Resources Data Requirements

Personnel

Question Asked	Response Option
Role/Position*	Select one: Required Roles/Positions: Epidemiologist/Epidemiologist Lead Evaluator/Evaluator Lead Financial/Budget Office contact Principal Investigator Program Coordinator/Program Coordinator Lead If Epidemiologist Selected, part of an Epidemiology “pool” – Yes/No Other Roles/Positions: Administrative Support Communication Specialist Health Educator Information Technology Specialist Other Manager Other (Specify) Guidance: Fill out OTHER personnel if funded by FOA.
Role/Position Status*	Select one: Vacant Filled
If Position Status = Vacant
Percent of Time Allocated to Asthma Program*	Enter percent
Title*	Enter text (100 characters/20 words)
If Position Status = Filled
Name*	Enter text (100 characters/20 words)
Status*	Select one: Active – Date Started with Program Inactive – Vacated Date
Title*	Enter text (100 characters/20 words)
Address*	Is this same as Program Mailing Address – Yes/No Address Line 1 Address Line 2 City, State, Zip
E-mail*	Enter text (100 characters/20 words)
Telephone*	Enter number
Percent of Time Allocated to Asthma Program*	Enter percent
Employment Type*	Select one: State Employee Contractor Other (specify) “Other” example: Bona Fide Agent Employee
Funding Source*	Select all that apply: Asthma cooperative agreement Other CDC funds (specify) State budget In-kind Other (specify)

*Required information

Contracts

Question Asked	Response Option
Status*	Select one: In progress Complete Pending Other (specify)
Primary Responsibility*	Select one: Administrative Support Communication/Media Epidemiology/Surveillance Evaluation Facilitation Information Technology Interventions Policy Analysis Program Coordination Training Other (specify)
Organization Name*	Enter text (100 characters/20 words)
Contact Name*	Enter text (100 characters/20 words)

*Required information

Statewide Partnership

Question Asked	Response Option
Structure of Statewide Partnership	Is there a state coalition? Select one: Yes No Are there in-state regional coalitions? Select one: Yes No Are there local coalitions? Select one: Yes No Is there a statewide advisory group or committee? Select one: Yes No Is there an internal Department of Health team that addresses asthma across programs? Select one: Yes No Is there an interdepartmental team that addresses asthma across state departments/units? Select one: Yes No
Role of State Asthma Program Staff Within Partnership Structure*	Enter text (2500 characters/500 words)
Number of Organizations, Agencies, or Programs Represented*	Enter number
Number of Individuals Included*	Enter number
Geographic Location of Partners Within State	Upload file (format = MS Word, PDF)
Location of State Asthma Program within Health Department*	Select one: Chronic Disease Prevention/Control Environmental Health Environmental/ Occupational Health Other (Specify)
State-Based Programs, Agencies or Associations Within State*	Select Yes, No, Don’t Know for each: Chronic Disease Prevention/Control Coordinated school health program Environmental Health Environmental Public Health Tracking Maternal and Child Health Occupational Health State Department of Education State Hospital Association State Medicaid Office State Medicare Office Tobacco Prevention/Control
Types of Partners to be Recruited	Select up to 3: General: Acute Care Facilities Business [Definition Available] Community Clinics/Federally Qualified Health Center (FQHC) Community/Neighborhood Organization Day Care/Preschool/Head Start Centers/Other Child Service Agency Developers or Construction Industry Elected Representative or Staff [Definition Available] Environmental Advocacy Group Housing Organization Individual(S) Affected By Asthma Local Asthma Coalitions And Other Local Health Coalitions Local Education Agency (LEA) Local Health Departments Managed Care Organization(S) Media Parent Teacher Association or Organization (PTA/PTO) Pharmaceutical Company Religious/Faith Based Organization School Management (K-12) [Definition Available] School of Environmental Studies School of Medicine School of Nursing School of Pharmacy School of Public Health School of Respiratory Therapy Other Groups, Agencies, or Collaboratives With Asthma Management As Part Of Their Mission Other Health Insurers/Plans Other School Advocate or Representative (K-12) [Definition Available] Health Care Professional Organization/Association Representing: Nurse Practitioners Nurses (LVN, RN) Pharmacists Physician Assistants Physicians Respiratory Therapists
	Racial or Ethnic Minority Service or Advocacy Organization Representing: American Indians/Alaska Natives Asians Blacks or African Americans Hispanics Native Hawaiians or Other Pacific Islanders Service Or Advocacy Organization That Represents The Following Susceptible Age Groups Or Geographic Areas: Children Elderly Rural Urban Other (specify)
Describe Approach For Establishing New Or Sustain Existing Partnerships	Enter text (2500 characters/500 words)
Other Funded Programs	Select all that apply: Environmental Public Health Tracking Program Sentinel Event Notification System for Occupational Risk (SENSOR) Coordinated school health program (DASH*) Other asthma program funded by DASH*
Collaboration with Other Funded Programs	Select all that apply: Environmental Public Health Tracking Program Sentinel Event Notification System for Occupational Risk (SENSOR) Coordinated school health program (DASH*) Other asthma program funded by DASH* If ‘none’, provide explanation – (Enter text 1000 characters/200 words)

*Required information

Partners

Question Asked	Response Option
Organization Name*	Enter text (100 characters/20 words) Help Text: If partner is an individual, then enter the individual’s name.
Type of Participation* Partnership Indicators, Q2	Select all that apply: State coalition In-state regional coalition Local coalition Statewide advisory group or committee
Partner Type*	Select one: General: Acute Care Facilities Business [Definition Available] Community Clinics/Federally Qualified Health Center (FQHC) Community/Neighborhood Organization Day Care/Preschool/Head Start Centers/Other Child Service Agency Developers or Construction Industry Elected Representative or Staff [Definition Available] Environmental Advocacy Group Housing Organization Individual(s) Affected By Asthma Local Asthma Coalitions And Other Local Health Coalitions Local Education Agency (LEA) Local Health Departments Managed Care Organization(s) Media Parent Teacher Association or Organization (PTA/PTO) Pharmaceutical Company Religious/Faith Based Organization School Management (K-12) [Definition Available] School of Environmental Studies School of Medicine School of Nursing School of Pharmacy School of Public Health School of Respiratory Therapy Other Groups, Agencies, or Collaboratives With Asthma Management As Part Of Their Mission Other Health Insurers/Plans Other School Advocate or Representative (K-12) [Definition Available] Health Care Professional Organization/Association Representing: Nurse Practitioners Nurses (LVN, RN) Pharmacists Physician Assistants Physicians Respiratory Therapists
	Racial or Ethnic Minority Service or Advocacy Organization Representing: American Indians/Alaska Natives Asians Blacks or African Americans Hispanics Native Hawaiians or Other Pacific Islanders Service Or Advocacy Organization That Represents The Following Susceptible Age Groups Or Geographic Areas: Children Elderly Rural Urban Other (specify)
Partner Contributions*	Select all that apply: Money Staff Time Meeting Space or Supplies Acquisition of New Funds [Definition Available] Endorses or Advocates For Program and/or Communicated or Disseminated Information About Program [Definition Available] Leads Goal or Objective in State Plan [Definition Available] Implements Intervention or Activities to Accomplish State Plan Member of Workgroup That Plans Interventions or Activities to Accomplish State Plan [Definition Available] Provides Data For Surveillance [Definition Available] Performs Data Analysis For Surveillance [Definition Available] Provides Data For Evaluation [Definition Available] Performs Data Analysis For Evaluation [[Definition Available] Other (Specify)
Type of Change in State Asthma Program Partner Agencies, Organizations, Institutions, Or Programs	Select one: Policy Staffing Funding Not applicable
Change Resulted From Involvement With State Asthma Program	Select one: Yes No

*Required information

State Plan

Question Asked	Response Option
Most Recent Date Revised Help text - If plan has not been revised, skip questions)	Enter Date (mm/yyyy)
Describe Grantee Collaboration with partner(s) to Develop the Plan	Enter text (1000 characters/200 words)
Describe how the Plan Addresses all Persons and Environments	Enter text (1000 characters/200 words)
Describe how the Plan will be Revised based upon Analysis of Surveillance Data, Program Evaluation Findings, and Other Factors that Affect State Support for Asthma	Enter text (1000 characters/200 words)
Describe how the Plan will Guide the Program	Enter text (1000 characters/200 words)
Attachments	Select one: State Asthma Plan State Asthma Plan-Approval Letter State Asthma Plan-Key Partner Letter Upload file (format = MS Word, PDF)

*Required information

Program Documents (Attachments)

Question Asked	Response Option
Document Name*	Enter text (100 characters/20 words)
Type*	Select one: Success Story Human Interest Story Organizational Chart Logic Model BRFSS Coordinator Letter of Support New Partner Letter of Support For Data
Attachment*	Upload file (format = MS Word, PDF)

Surveillance

Question Asked	Response Option
Data Sources* (Help text – Include data sources that are or are not supported/collected by the state asthma program, and data sources that are or are not accessible to the state asthma program)	Select One: Vital Statistics-Mortality Statewide Hospital Discharge Statewide Emergency Department Visits Health Maintenance Organization (HMO) Data Other Private Insurance Data Medicare Medicaid State Children’s Health Insurance Program (SCHIP) Youth Risk Behavior Survey (YRBS) – Asthma questions Youth Tobacco Survey (YTS) – Asthma questions BRFSS- Core (Adult Prevalence) BRFSS- Child Prevalence Optional Module BRFSS- Adult History Optional Module BRFSS Random Child Selection Module BRFSS- Child Call Back Survey BRFSS Adult Call Back Survey National Asthma Survey National Survey of Children’s Health (SLAITS) Worker’s Compensation Claims Mandatory Occupational Reporting BRFSS State-Added Work-Related Asthma Air Quality Monitoring Air Quality Modeling Poison Control Center School Absenteeism Data School Nurse Reports Physician Office Visit Data Prescription Drug Data Over-the Counter Drug Data State specific survey (specify): Select Years (for each selected data source): 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 Note: Year list will be dynamic to show 1998 through current year
Data Sources* (continued) (Help text – Include data sources that are or are not supported/collected by the state asthma program, and data sources that are or are not accessible to the state asthma program)	Select one - Analyzed By (for each selected data source): Asthma Surveillance Staff Other Unknown Not Analyzed Select all that apply – Analysis Barriers Questionable Cleanliness of Data or Quality of Data Analysis Data Sharing Issues Asthma Surveillance Staff Time Asthma Surveillance Staff Time Knowledge of Data Data Not Yet Available Other (specify) Note: Question is visible only if “Data Source’ = Vital Statistics, Statewide Hospital Discharge, or BRFSS and “Analyzed By” for one of the past 3 years = Unknown or Not Analyzed

Question Asked	Response Option
Name of Other Data Sources Used	Enter text (100 characters/20 words)
Purpose	Enter text (1000 characters/200 words)
Data Collection Period	Enter range of month and year
Data Collection Methods	Enter text (1000 characters/200 words)
Data Collection Frequency	Select one: On-going collection Single collection
Populations Sampled	Age Select all that apply: Children with asthma (0-5 years) Children with asthma (6-12 years) Adolescents with asthma (13-17 years) Adolescents with asthma (18 years) Adults with asthma (19-64 years) Elderly with asthma (65 years of age and older) Sex Select all that apply: Male Female Race Select all that apply: African American or Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander White Multi-racial General Population Other Race/Ethnicity (specify): Ethnicity Select all that apply: Hispanic or Latino Not Hispanic or Latino Geography Select all that apply: Urban area Rural area Suburban area Specific local public health district/region Other (specify):
Measures	Select all that apply: Prevalence Incidence Age at diagnosis Asthma mortality Hospital discharge Emergency department visit Outpatient visit Urgent visit Office visit Daytime symptoms Sleep disturbance Days of activity limitations Symptom free days Routine care visits Use of rescue medication Use of control medication Prescriptions Cost as a barrier Days of work or school missed Degree of activity limitation Work-related asthma Environmental exposure and risk reduction scale Complimentary and alternative therapy Other (specify)
Prevalence Measure	Select one: Lifetime asthma prevalence – Adults Current asthma prevalence – Adults Lifetime asthma prevalence – Children Current asthma prevalence – Children Select Years (for each selected prevalence): 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 Note: Year list will be dynamic to show 1998 through current year Select all that apply: BRFSS BRFSS Child Asthma Prevalence Module National Survey of Children’s Health Other (specify)
Calculation of Mortality and Hospitalization Measures for Asthma Mortality (Underlying Cause) (Help text -If a measure has been calculated by aggregating data across years (e.g., mortality rate for 2000-2005) select the individual years that are included in this aggregate figure)	Select one: Number of deaths Crude mortality rate Age-adjusted mortality rate Select Years (for each selected): 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 Note: Year list will be dynamic to show 1998 through current year
Calculation of Mortality and Hospitalization Measures for Asthma Hospital Discharge (First listed diagnosis) (Help text -If a measure has been calculated by aggregating data across years (e.g., mortality rate for 2000-2005) select the individual years that are included in this aggregate figure)	Select one: Number of hospital discharges Crude hospital discharge rate Age-adjusted hospital discharge rate Select Years (for each selected): 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 Note: Year list will be dynamic to show 1998 through current year
Analysis of Survey Questions on Asthma Education	For Children, Select One: Have you or {child's name} ever taken a course or class on how to manage {his/her} asthma? Has a doctor or other health professional ever taught you or {child's name}...to recognize early signs or symptoms of an asthma episode? Has a doctor or other health professional ever taught you or {child's name}...what to do during an asthma episode or attack? Has a doctor or other health professional ever taught you or {child's name}...how to use a peak flow meter to adjust his/her daily medications? Has a doctor or other health professional EVER given you or {child's name}...an asthma action plan? Select Years (for each selected): 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 Note: Year list will be dynamic to show 1998 through current year Select all that apply: BRFSS call-back Other (specify) We do not ask this question For Adults, Select One: Have you ever taken a course or class on how to manage {his/her} asthma? Has a doctor or other health professional ever taught you...how to recognize early signs or symptoms of an asthma episode?
	Has a doctor or other health professional ever taught you ...what to do during an asthma episode or attack? Has a doctor or other health professional ever taught you ...how to use a peak flow meter to adjust his/her daily medications? Has a doctor or other health professional EVER given you...an asthma action plan? Select Years (for each selected): 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 Note: Year list will be dynamic to show 1998 through current year Select all that apply: BRFSS call-back Other (specify) We do not ask this question
Additional Measures	Select One: Prevalence Incidence Age at diagnosis Asthma mortality rate- Multiple cause Hospital discharge rate- Multiple diagnoses Hospitalizations (rate) Hospitalizations (number) Emergency department visit (rate) Emergency department visits (number) Outpatient visit (rate) Outpatient visit (number) Urgent visit (rate) Urgent visit (number) Office visit (rate) Office visit (number) Daytime symptoms Sleep disturbance Days of activity limitations Symptom free days Routine care visits Use of rescue medication Use of control medication Prescriptions Cost as a barrier- Primary care Cost as a barrier- Specialist care Cost as a barrier- Prescriptions Days of work or school missed Degree of activity limitation Work-related asthma Environmental exposure and risk reduction scale Complimentary and alternative therapy Other
Additional Measures (continued)	Data Source (Select One): Vital statistics- mortality Hospital discharge data BRFSS- Adult History Optional Module BRFSS- Child Call Back Survey BRFSS- Adult Call Back Survey BRFSS- State added Worker’s Compensation Claims Emergency Department Visits Youth Risk Behavior Survey (YRBS) Youth Tobacco Survey (YTS) Health Maintenance Organization (HMO) data Private insurance data other than HMO Medicare Medicaid Poison Control Center School Absenteeism Data School Nurse Reports Other
Limitations	Enter text (1000 characters/200 words)

*Required information

Question Asked	Response Option
Hospital Discharges
Hospital Discharge Data Year	Select one: 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 Note: Year list will be dynamic to show 1998 through current year
Number Of Asthma Hospital Discharges With Asthma As The First Listed Diagnosis*	Enter number for each age (allow ###,###,###): Less than 1 year 1-4 years 5-9 years 10 –14 years 15 - 17 years 18 - 19 years 20 – 24 years 25 – 29 years 30 – 34 years 35 – 39 years 40 – 44 years 45 – 49 years 50 – 54 years 55 – 59 years 60 – 64 years 65 – 69 years 70 – 74 years 75 – 79 years 80 – 84 years 85 years or more
Emergency Department Visits
Emergency Department Visit Data Year*	Select one: 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 Note: Year list will be dynamic to show 1998 through current year
Number of Hospitals Included in Discharge Data Analysis*	Enter number (allow ###,###)
Number of Hospitals that Provided Data to Discharge Dataset*	Enter number (allow ###,###)
Number of Licensed Beds Included in Discharge Data Analysis*	Enter number (allow ###,###)
Number of Licensed Beds in Hospitals that Provided Data to Discharge Dataset*	Enter number (allow ###,###)
Types of Hospital Not Contained in Discharge Dataset*	Select all that apply: Veteran’s Administration Hospitals Military Hospitals Psychiatric/Mental Health Hospitals Prison Hospitals Indian Health Service Hospital Other (specify)
Specify States in the Dataset with Residents Having Hospital Discharges in Out-of-State Hospitals*	Enter text (1000 characters, 200 words)
Number Of Asthma Emergency Department Visits With Asthma As The First Listed Diagnosis*	Enter number for each age (allow ###,###,###): Less than 1 year 1-4 years 5-9 years 10 –14 years 15 - 17 years 18 - 19 years 20 – 24 years 25 – 29 years 30 – 34 years 35 – 39 years 40 – 44 years 45 – 49 years 50 – 54 years 55 – 59 years 60 – 64 years 65 – 69 years 70 – 74 years 75 – 79 years 80 – 84 years 85 years or more
Availability of Data for an Emergency Department Visit Resulting in a Hospital Admission*	Select one: Emergency Department Data File Only Hospital Discharge Data File Only Both The Emergency Department Data File And The Hospital Discharge Data File Other (specify): Unknown

*Required information

Data Gaps & Barriers

Question Asked	Response Option
Gaps Encountered	Enter text (1000 characters/200 words) Help Text: Specify data gaps by describing data that is not currently available, but is needed to enhance existing asthma surveillance in the state. If needed, identify specific partners who will assist in obtaining these data.
Barriers Encountered	Enter text (1000 characters/200 words) Help Text: Identify specific barriers to accessing data that is not currently available, but is needed to enhance existing asthma surveillance in the state.

*Required information

Work Plan Data Requirements

Infrastructure/Intervention Goals (1-5 Years)

Definition: Goals indicate the overall mission or purpose of the program to be accomplished in specific areas through the implementation of measurable objectives and activities.

Question Asked	Response Option
Goal Statement	Enter text (200 characters/40 words)
Type	Select one: Infrastructure Surveillance State Asthma Plan Partnerships Program Evaluation Management and Staffing Sustainability Intervention
Category	If Infrastructure - Select one: Core Component Surveillance Expanded Component Disparities Expanded Component If Intervention - Select one: Core Component Disparities Expanded Component Intervention Expanded Component
Related FOA Goal	Select one: Reduce asthma disparities among populations disproportionately affected by asthma as compared to the general population with asthma. Reduce the state asthma hospitalization rate. Increase the proportion of people with current asthma who report that they have received self-management education. Not applicable
Desired Outcome	Select one: Decrease in asthma disparities Decrease in asthma mortality Decrease in asthma morbidity Decrease in asthma symptoms

*Required information

Intervention Objectives (Annual)

Definition: Objectives represent the steps a program will take to achieve each goal. Each objective must be related to and contribute directly to the accomplishment of the stated goals.

Question Asked		Response Option
Intervention Name		Enter text (100 characters/20 words)
Related Work Plan Goal		Select one: List of Intervention Work Plan Goals and its related Category
Related State Asthma Plan Goal		Enter text (500 characters/100 words)
Rationale for Selecting Intervention		Select all that apply: Addresses a goal in the state asthma plan Limited funding to support an intervention- this intervention could reasonably be implemented with the available funds Results from analyses of surveillance data indicated there was a need present that this intervention would address Legislature mandated implementation of this intervention Evidence obtained that this intervention is effective Strong partner preferences existed for this intervention disparity indentified that needs to be addressed (not identified through surveillance) Other (specify)
Implementation Strategy		Select all that apply: Public awareness activities (e.g., media campaigns, public service announcements) Training/educational session(s) (e.g., Open Airways for Schools (OAS), Physician Asthma Care Education (PACE), Asthma Care Training (ACT)) Policy development and/or implementation (e.g., model policies, policy implementation guidelines, policy procedures (e.g., standard operating procedures (SOP)) Environmental assessment and/or remediation Case management and/or care coordination Other (specify)
Measure		Direction of Change - Select one: Increase Decrease Maintain Unit of Measurement - Select one: Number Percent Rate What will be measured – Select one: Attitudes Awareness Environmental Management Policy Provider Management Quality of Life School/Work Days Missed Self Management Other (specify)
Measure (continued)		Baseline – Enter number, or select “Unknown” (Help Text – guide users to define unknown baseline as an Activity) Target – Enter number Primary Data Source – Select one List of data sources from “Core Data Sources” List of data sources from “Other Data Sources”
Intervention Recipient		Select all that apply: Type: Certified Asthma Educators (AE-C) Childcare/Daycare providers Community health workers Community organizations Elected officials Health care providers (specify) Individuals with asthma Parents/caregivers of people with asthma Pharmacists School Faculty/Staff Administration Administrative Support Bus Driver Coach/Physical Education Teacher Custodial Staff Nurse/Health Aide Teacher Location: Rural Urban Suburban
Intervention Beneficiary		Select one: General Population Disparate Population If Disparate Population, Select all that apply: Age: Individuals ages 0-5 years with asthma Individuals ages 6-12 years with asthma Individuals ages 13-18 years with asthma Individuals ages 19-64 years with asthma Individuals ages 65 or more years with asthma Geography (Select all that apply) Urban area Rural area Suburban area Other (specify) Socioeconomic Status Low income Low literacy Gender Males Females Race African American or Black American Indian or Alaskan Native Asian Native Hawaiian or Other Pacific Islander White Ethnicity Hispanic or Latino Not Hispanic or Latino
Setting		Select all that apply: Childcare/Daycare Center College//University Community Center (e.g. YMCA, senior center) Correctional Facility Emergency Department Government Office Head Start Health Care Provider Office/Clinic Health Insurance Office Home Hospital Library Nursing Home Pharmacy Place of Worship Schools (K-12) Worksite Other (specify)
Priority Messages		Select all that apply: Inhaled Corticosteroid Asthma Action Plan Asthma Severity Asthma Control Follow-up Visits Allergen and Irritant Exposure Control
Contextual Factors That Pose Barriers		Select all that apply: Legislative Financial Personnel Social Partnership Political Contracts/Grants Other (specify) Please describe - Enter text (1000 characters/200 words)
Contextual Factors That Facilitate Success		Select all that apply: Legislative Financial Personnel Social Partnership Political Contracts/Grants Other (specify) Please describe - Enter text (1000 characters/200 words)
Funding		Select one: Fully funded by CDC state asthma program dollars Partially funded by CDC state asthma program dollars Not funded by CDC state asthma program dollars
Begin Date		Enter month and year
End Date		Enter month and year
Progress
*Progress Period	Select one: First 6 Months Second 6 Months
*Objective’s Target Met	Select one: Met Unmet Ongoing
*Current Measurement	Enter text (20 characters) or select “Unknown at this time”
*Describe Progress	Enter text (3000 characters)
*Facilitating Factors of Success	Enter text (3000 characters)
*Barriers/Issues Encountered	Enter text (3000 characters)
*Plans to Overcome Barriers/Issues Encountered	Enter text (3000 characters)
Unanticipated Outcomes Resulting from the Objective	Enter text (3000 characters)

*Required information

Infrastructure Objectives (Annual)

Definition: Objectives represent the steps a program will take to achieve each goal. Each objective must be related to and contribute directly to the accomplishment of the stated goals.

Question Asked	Response Option
Objective Name	Enter text (100 characters/20 words)
Related Work Plan Goal	Select one: List of Infrastructure Work Plan Goals and its related Category
Related State Asthma Plan Goal	Enter text (500 characters/100 words)
Measure	Direction of Change - Select one: Increase Decrease Maintain Unit of Measurement - Select one: Number Percent Rate Baseline – Enter number, or select “Unknown” (Help Text – guide users to define unknown baseline as an Activity) Target – Enter number What will be measured – Enter text (1000 characters/200 words) Data Source – Enter text (1000 characters/200 words)
Contextual Factors That Pose Barriers	Enter text (1000 characters/200 words)
Contextual Factors That Facilitate Success	Enter text (1000 characters/200 words)
Funding	Select one: Fully funded by CDC state asthma program dollars Partially funded by CDC state asthma program dollars Not funded by CDC state asthma program dollars
Begin Date	Enter month and year
End Date	Enter month and year
Progress
*Progress Period	Select one: First 6 Months Second 6 Months
*Objective’s Target Met	Select one: Met Unmet Ongoing
*Current Measurement	Enter text (20 characters) or select “Unknown at this time”
*Describe Progress	Enter text (3000 characters)
*Facilitating Factors of Success	Enter text (3000 characters)
*Barriers/Issues Encountered	Enter text (3000 characters)
*Plans to Overcome Barriers/Issues Encountered	Enter text (3000 characters)
Unanticipated Outcomes Resulting from the Objective	Enter text (3000 characters)

*Required information

Activities

Activities: Activities represent major tasks required to accomplish each objective. Identify up to FOUR activities.

Question Asked	Response Option
Activity Name	Enter text (100 characters/20 words)
Related Annual Work Plan Objective	Relationship automatically determined by objective user is currently associating activities to.
Activity Description	Enter text (1000 characters/200 words)
Assigned Lead Staff	Select one: List of names from personnel section
Assigned Lead Staff Responsibility	Enter text (200 characters/40 words)
Other Assigned Staff	Select all that apply: List of names from personnel section
Other Assigned Staff Responsibility	Enter text (200 characters/40 words)
Assigned Contractors	Select all that apply: List of names from contractor section
Assigned Contractors Responsibility	Enter text (200 characters/40 words)
Assigned Partners	Select all that apply: List of names from partner section
Assigned Partners Responsibility	Enter text (200 characters/40 words)
Begin Date (validate date is not prior to first day of budget year)	Enter month and year
End Date (validate date is prior or equal to last day of budget year)	Enter month and year

Evaluation Data Requirements

Strategic Evaluation

Question Asked	Response Option
Strategic Evaluation Plan Status*	Select one: Not Planned to be Evaluation Planning Stage In Progress Completed
Date of Most Recently Revised Strategic Evaluation Plan*	Enter date (mm/yyyy)
Strategic Program Evaluation Plan*	Upload file (format = MS Word, PDF)

*Required information

Program Area Evaluation

Question Asked	Response Option
Program Area Being Evaluated*	Select one: Core Partnerships Surveillance Interventions Expanded Opportunities Surveillance Interventions Disparities
Program Area Evaluation Purpose*	Enter text (500 characters/100 words)
Program Area Evaluation Status*	Select one: Planning In Progress Completed
Program Area Evaluation Plan*	Upload file (format = MS Word, PDF)
Primary Responsibility for Conducting Evaluation*	Select one: Contractor Asthma Program Staff Evaluator Epidemiologist Program Coordinator Other (specify):
Evaluation Method and Instrument*	Select all that apply: If “Program Area Being Evaluated” = Partnerships Member Surveys New Existing Modified Post Meeting Effectiveness Surveys New Existing Modified Key Informant Interviews New Existing Modified Informal Discussion or Feedback New Existing Modified Other (specify) New Existing Modified If “Program Area Being Evaluated” = Surveillance User Surveys New Existing Modified User Focus Groups New Existing Modified Key Informant Interviews New Existing Modified Informal Discussion or Feedback New Existing Modified Other (specify) New Existing Modified
Evaluation Method and Instrument (continued)	If “Program Area Being Evaluated” = Intervention Intervention Staff Interviews New Existing Modified Intervention Beneficiary Interviews New Existing Modified Surveys New Existing Modified Focus Groups New Existing Modified Observations New Existing Modified Data Abstraction New Existing Modified Other (specify) New Existing Modified
Data Set Used for Evaluation*	Display only if “Program Area Being Evaluated” = Surveillance Select all that apply: BRFSS Adult Asthma Call-Back BRFSS Adult History Module BRFSS Child Asthma Call-Back BRFSS Child Prevalence Module BRFSS Core Adult Prevalence BRFSS Random Child Selection Module Death Records or Vital Statistics Hospital Discharge Other (specify):
Surveillance Products Evaluated*	Display only if “Program Area Being Evaluated” = Surveillance Select all that apply: Burden Report Data Tables on Website Fact Sheets, Newsletters, or Quarterly Reports Presentations Reports on Special Topics Other (Please specify):
Recipients of Evaluation Results*	Select all that apply: Asthma Program Staff and Other Health Department Staff Funders General Public Other State Asthma Programs Partners Policy Makers Other (specify)
How Evaluation Results Will be Used*	Select all that apply: Assess process and practice as it is implemented Develop standardized tools Develop strategies to make necessary changes to operations Garner political support by demonstrating effectiveness of a program Identify areas for future research and evaluation Identify effective policies, procedures or practices for replication Organize key information for training staff and informing those outside program Prioritize program activities and resources Target areas for enhancement or improvement Understand implications of policy and guidelines on the program Other (specify)
How Results Will Be Disseminated*	Select all that apply: Journal Article and/or Peer Reviewed Publication Personal Discussions Posts to Website(s) Presentations (In Person or Video) Web Conferences or Teleconferences Working Session Meetings Written Medium (Newsletter, Brochures, Memorandum, E-Mail, etc.) Other (specify)
Lessons Learned*	Enter text (500 characters/100 words)

*Required information

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