0920-0255 Att3B_initial_quest_tele_scriptClean

Resources and Services Database of the CDC National Prevention Information Network

0920-0255

Attachment 3-B

Initial Questionnaire Telephone

Form Approved

OMB No.0920-0255

Exp. date: ­­01/31/2014

CDC National Prevention Information Network

Public reporting burden of this collection of information is estimated to vary from 10-30 minutes per response, with average of 20 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, or respond to a collection of information unless it displays a currently valid 0MB 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 20222; ATTN: PRA (0920-0255).

Initial Questionnaire Telephone Script

Hello, my name is _______________________ and I am calling from the CDC National Prevention Information Network.

The National Prevention Information Network (NPIN) is a clearinghouse service provided by the U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention (CDC). A primary goal of NPIN is to serve as a comprehensive source for information about organizations in the United States that provide HIV/AIDS-, Viral Hepatitis-, STD-, and TB-related services or resources. The clearinghouse is authorized to collect this information by Section 301 of the Public Health Service Act (42 U.S.C 241). This information is organized and maintained by the NPIN online database. The mission of NPIN is to serve the information needs of state and local HIV/AIDS/Viral Hepatitis/STD/TB program personnel and other professionals. The general public also has access to this information from the NPIN website or by calling CDC-INFO (formerly the CDC National AIDS and STD Hotline), which provides referrals from the NPIN database to local service organizations.

We have identified your organization as providing services or resources related to HIV/AIDS, Viral Hepatitis, STDs, and/or TB and I am calling to obtain information about your organization and its services. The information you provide about your organization or program will be added to the NPIN database and will be made available to professionals and other users. Your participation is voluntary.

Are you willing to participate in this data collection at this time? If yes, continue with questionnaire. If no, thank respondent for their time and end call.

I. ORGANIZATION INFORMATION

1. Please tell me your organization’s name, including any department, division or office.

______________________________________________________________

______________________________________________________________

____________________________________________________________________________________________________________________________

2. Does your organization have (use) an acronym for your company name? If yes, what is it?

Acronym: _____________________________________________________

3. Is your organization known by any other name? If yes, what is it?

Other name:___________________________________________________

Previous name(s):_____________________________________________

Program name(s):______________________________________________

4. What is the street address for your organizations?

Street 1: ______________________________________________________________Street 2: ______________________________________________________________

City: ______________________________________________________________

State: ______________________________________________________________

ZIP: ______________________________________________________________

County: ______________________________________________________________

Country: ______________________________________________________________

5. Please tell me your main phone number and your fax number? Does your organization have a toll-free number, a TTD number, a hotline number, or a Spanish-speaking number? Are there any other phone numbers we should have?

Main Telephone :(______)_____________________________________

Fax: (______)________________________________________________

Toll-Free: (______)__________________________________________

Hotline: (______)____________________________________________

TDD/Deaf Access: (______)____________________________________

Spanish: (______)____________________________________________

Publications: (______)_______________________________________

Other: (______)______________________________________________

5. Does your organization have an e-mail address? A website?

E-mail Address: ______________________________________________________________

Website Address: ______________________________________________________________

5. Please tell me the name(s) of key staff to contact for updating your organization’s information. Please provide the title, and email address. This information is only used internally and is not released to the public.

Name:_______________________ Title:_______________________

E-mail: _______________________

Name:_______________________ Title:_______________________

E-mail: _______________________

Name:_______________________ Title:_______________________

E-mail: _______________________

5. What geographic area(s) does your organization serve?

Cities:_______________________________________________________

Counties:_____________________________________________________

States: __________________________________________________

Metropolitan Area:____________________________________________

Countries:____________________________________________________

Other:________________________________________________________

5. Is your organization non-profit, governmental, or commercial? _____________________________________

[To interviewer: if respondent answers governmental or commercial, skip to Question 12.]

5. If your organization is non-profit, does it have 501c3 status? ________________________________________

5. If your organization is not-for-profit, is it affiliated with a religion or religious denomination?

 Yes  No

If yes, which religion or denomination? ___________________________________________________________

12. Is your organization minority owned or operated?

 Yes  No

13. What kinds of HIV/AIDS, Viral Hepatitis, STD, and/or TB work does your organization do?

______________________________________________________________

______________________________________________________________

____________________________________________________________________________________________________________________________

II. CLIENT INFORMATION

1. What are the primary client groups your organization serves or targets?

______________________________________________________________

______________________________________________________________

____________________________________________________________________________________________________________________________

III. CLIENT SERVICES OF YOUR ORGANIZATION

1. Does your organization offer services in any language other than English?  Yes  No

If yes, what languages? ____________________________________________________________

2. Does your organization provide direct services to clients who are infected or affected by HIV, STDs, or TB?  Yes  No

[TO INTERVIEWER, IF RESPONDENT ANSWERS NO, SKIP TO SECTION IV.]

3. What disease testing services does your organization offer?

[TO INTERVIEWER: Read choices and check services offered by organization.]

 HIV Test Counseling

 Conventional Blood HIV Testing

 Conventional Oral HIV Testing

 Rapid Oral HIV Testing

 Rapid Blood HIV Testing

 Home HIV Test Kits

 Partner notification

 Mobile Testing

 TB Testing

 Viral Hepatitis

Testing

 Hepatitis A Testing

 Hepatitis B Testing

 Hepatitis C Testing

 Hepatitis C Rapid

Testing

 STD Testing

 Chlamydia Testing

 Syphilis Testing

 Gonorrhea Testing

 Herpes Testing

 Home STD Test Kits

4. What medical treatment services does your organization offer?

[TO INTERVIEWER: Read choices and check services offered by organization.]

 Clinical Trials

 Medical Adherence Education and Counseling

 Dental Care

 Direct Observed Therapy (DOT) Short Course

 Family Planning

 HAV Immunizations

 HBV Immunizations

 HPV Immunization

 Gynecological Care

 Primary Care

 STD Treatment

 Viral Hepatitis

Treatment

 Hepatitis B Treatment

 Hepatitis C Treatment

 TB Treatment

 Other/Comments: __________________

5. What HIV/AIDS treatments and therapies does your organization offer? [TO INTERVIEWER: Read choices and check services offered by organization.]

 Alternative/Complementary Medicine

 HIV/AIDS Medical Treatment

 Nutrition Therapy

 Other/Comments: __________________

6. What counseling or mental health services does your organization offer? [TO INTERVIEWER: Read choices and check services offered by organization.]

 Counseling

 Sexuality Counseling

 Substance Abuse Treatment

7. Does your organization offer any support groups?

Yes No

8. Does your organization provide any FAITH BASED AIDS SERVICES?

 Yes  No

9. What support services does your organization offer?

[TO INTERVIEWER: Read choices and check services offered by organization.]

 Case Management,

Administration

 Food Services

 Child Care

 Home Care Assistance

 Respite Care Services

 Housing Services

 Housing Opportunities for Persons with AIDS / HOPWA

 Transportation Services

10. Does your organization offer referral services?

 Yes  No

11. Does your organization offer legal services?

 Yes  No

12. What financial assistance and services does your organization offer? [TO INTERVIEWER: Read choices and check services offered by organization.]

 Emergency Financial

Assistance

 Housing Financial Assistance

 Financial Assistance to Individuals

 Drug Purchasing Assistance, including AIDS Drug Assistance Programs (ADAP)

13. Does your organization provide funding to organizations?

 Yes  No

IV. HOTLINE/INFORMATION/RESEARCH/EDUCATION SERVICES OF YOUR ORGANIZATION

1. Does your organization provide hotline, information, research, education, or advocacy services specific to HIV/AIDS, Viral Hepatitis, STDs, or TB?

 Yes  No

[TO INTERVIEWER: IF NO, SKIP TO SECTION V.]

2. HOTLINE SERVICES

2a. Does your organization operate a hotline?  Yes  No

2b. Is your hotline:

An AIDS hotline?  Yes  No

An STD hotline?  Yes  No

A TB hotline?  Yes  No

A viral hepatitis hotline?  Yes  No

If no, what type of hotline do you operate? ______________________________________________________________

2c. What kinds of services are provided by your hotline? What is the hotline number?

Type __________________Telephone #___________________

______________________________________________________________

____________________________________________________________________________________________________________________________

3. What information services are offered by your organization? [TO INTERVIEWER: Read choices and check services offered by organization.]

 Electronic Information Resources

 Materials – Print/Audiovisual)

 Treatment Information

4. What kind of research does your organization conduct?

[TO INTERVIEWER: Read choices and check services offered by organization.]

 Behavioral Research  Other Research

5. What kind of prevention education services does your organization offer? [TO INTERVIEWER: Read choices and check services offered by organization.]

 Curriculum Development

 Conferences

 Safer Sex Education

 Health Professional Education

 Hepatitis

Prevention/Education

 HIV/AIDS Prevention/Education

 Nutrition Education

 Condom / Female Condom /Dental Dam Distribution

 Needle Cleaning, Needle Exchange or Needle Distribution

 Peer Education

 Street Outreach

 Public Awareness Campaigns

 NAMES Quilt

 Speakers Bureau

 STD Prevention/Education

 TB Prevention/Education

 Training Programs

 Train the Trainer

 Abstinence Education

 Capacity Building

 Harm Reduction

 Networking

 Technical Assistance

6. Does your organization provide EVIDENCE-BASED BEHAVIORAL INTERVENTIONS?  Yes  No

If yes, what are the types of evidence-based behavioral interventions (level, risk category, race/ethnicity, sex/gender) you provide?

________________________________________________________________________________________________________________________________________________________________________________________________

7. Does your organization provide EVIDENCE-BASED BEHAVIORAL INTERVENTION TRAINING?  Yes  No

If yes, are the types of evidence-based behavioral intervention training (level, risk category, race/ethnicity, sex/gender) you provide?

________________________________________________________________________________________________________________________________________________________________________________________________

8. Does your organization provide ONLINE TRAINING PROGRAMS?

 Yes  No

If yes, what online training programs do you provide?

________________________________________________________________________________________________________________________________________________________________________________________________

9. Does your organization offer workplace programs?

 Yes  No

10. Does your organization offer planning and administration services?

 Yes  No

[TO INTERVIEWER: Read choices and check services offered by organization.]

 Program Administration

 Advocacy/Activism

 Community Planning

 Grant Management

V. ACCESS PROCEDURES

Please check applicable items below and use the lines for explanation or additional information

1. What are your business (service) hours?

_______________________________________________________

2. Does your organization require appointments? Are walk-ins accepted?

 Appointment required  Walk-ins accepted

3. Are fees charged for services? If yes, does your organization offer a sliding fee scale?

 No fee.

 Fee.

• Fee. Sliding scale.

4. Does your organization accept Medicaid, Medicare, and Insurance?

 Medicaid  Medicare  Insurance

5. Does your organization offer free testing?

 Yes  No

6. Does your organization offer free STD testing?  Yes  No

6. Does your organization offer free Hepatitis B

testing?  Yes  No

6. Does your organization offer free Hepatitis C

testing?  Yes  No

6. Does your organization accept donations?

 Yes  No

10. Is your organization handicapped accessible?

 Yes  No

11. Are there any restrictions on eligibility (for services)? If so, what kinds of restrictions do you enforce?

_________________________­­­­­­­­­­­­­­­­­­­­­­­­­_________________________________

VI. ADDITIONAL COMMENTS

The National Prevention Information Network (NPIN) and the CDC-INFO (formerly the CDC National AIDS Hotline) Hotline refer callers to organizations every day. We want to be certain that the information we provide about your organization is as complete as possible. Are there any other details about your organization that have not been captured in this questionnaire?

___________________________________________________________

___________________________________________________________

______________________________________________________________________________________________________________________

___________________________________________________________

Thank you for completing this survey! We appreciate your time and effort.