Site Visit Interviewee Form

Attachment 6A

Site Visit Suggested Interviewee Form

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Identifying Interviewees Instructions

Public reporting burden of this collection of information is estimated to average one hour 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

The purpose of Suggested Interviewees Form is to determine, in advance, individuals who could be interviewed during the site visit. Please use the form to identify people who represent the categories of program functions that we are interested in learning about. Because every program uses its own names, terms, and arrangements, the information on the tables will help you to be clear about what types of persons we would like to talk with.

Please return the Suggested Interviewees Form to ____________ at ICF International by [insert date].

After you have returned the form, an ICF International representative will follow up with a call to you to confirm what specific people are to be interviewed. From the list of possible interviewees you provide, we will work with you to finalize the number and schedule of interviews that the site visitors will conduct during the visit.

• Provide the title, name, and program involvement for each suggested interviewee as indicated for each of the categories listed.

• Return the form to ICF International by e-mail (so’[email protected]) for review. An ICF International representative will arrange a follow-up call with you and the assigned site visitors to review the list and to ensure that appropriate people have been identified for the interviews.

• After the telephone review, make any needed revisions. An ICF International representative will provide you with instructions and a template for use in confirming each of the selected persons to be interviewed and at what time and location.

Suggested Interviewees Form for [Insert Name]

The purpose of this form is to identify a range of people involved with your colorectal cancer screening program and to note how they are involved. Please list the names of the persons involved in the design, delivery, and/or evaluation of the program, along with their titles and the main activities with which they are involved.

Program Director(s): Those persons responsible for leading the program. “Program directors” oversee the program and monitor its implementation. These positions may be held XXXX. Time Required per Interview: 2 hours
Title/Position	Name	Main Program Involvement
Program Coordinator/Manager(s): Those persons responsible for managing the day-to-day implementation of the program. “Program coordinators/managers” provide managerial oversight for the program on the ground level. Time Required per Interview: 1 hour
Title/Position	Name	Main Program Involvement
Evaluation Lead(s): Those persons responsible for evaluating the program. These positions may be held within state departments or may be contracted out to other companies. Time Required per Interview: 1 hour
Title/Position	Name	Main Program Involvement
Program Staff: Those persons who are employed by the program and are responsible for program-related tasks. Examples of program staff include, but are not limited to, patient navigators, nurse coordinators, data managers, recruitment coordinators, and health care providers. Time Required per Interview: 1 hour
Title/Position	Name	Main Program Involvement
Program Partners: Those persons and organizations associated with program implementation through partnerships, both formal and informal. Examples of partners include, but are not limited to medical advisory board members, director/manager/coordinator of the program(s) with which CRCCP is actively working on integration (e.g., National Breast and Cervical Cancer Early Detection Program coordinator), and community organizations. Time Required per Interview: 1 hour
Title/Position	Name	Main Program Involvement