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Attachment F: 

Supplemental SOTS Survey Questions

Form Approved
OMB No. 0920-0916
Exp. Date: 1/13/2014










BIC Capacity Indicators Questionnaire 



    I. Infrastructure: Workforce

    1. How long has the full time director been the injury program director? 
[Record # of years]

    2. How long has the full time director worked in the injury prevention field? 
[Record # of years]

    3. What type of training (or academic preparation) does the injury program director have? (Check all that apply).
Highest Education Attainment:
    • Bachelors degree  
    • Graduate degree (e.g., MPH, MS, MPA, DrPH, PhD); NO graduate-level curriculum related to injury prevention 
    • Graduate degree (e.g. MPH, MS, MPA, DrPH, PhD); graduate-level curriculum related to injury prevention 
Trainings and/or Certifications: 
    • No Training
    • Specific injury prevention training program/fellowship that is university-affiliated, sponsored by a professional association, and/or sponsored by a federal government agency  (e.g., Johns Hopkins Summer Institute, PREVENT violence prevention program, Indian Health Service Program Development or Epidemiology fellowship, University of Michigan Summer Institute) 
    • Professional development webinars, short trainings, mentoring, etc.
    • Other (please explain)


    4. What type of training does the epidemiologist/ statistician/data professional have? If you have more than one person devoted to this role, please provide the highest level of training attained by any person in this role. 
    a. Graduate degree in epidemiology or biostatistics 
    b. Other graduate degree in a quantitative science, such as engineering, economics, demography, etc. 
    c. Other graduate degree, not-quantitatively related (please explain) 
    d. Undergraduate degree ( please explain) 


    5. What type of training does the program evaluator have? If you have more than one person devoted to this role, please provide the highest level of training attained by any person in this role.
    a. Graduate degree that included specific coursework in program evaluation, such as public health program evaluation, education, or policy evaluation 
    b. Other graduate degree (please explain)
    c. Undergraduate degree (please explain) 


    11. Does your VIP program have access to staff support for communications?
    a. Yes, within the VIP program
    b. Yes, within the state health department
    c. Yes, by consultant
    d. Yes, by Injury Control Research Center or other academic center 
    e. Yes, other (please specify)
    f. No

[If YES (a-e) go to #12. If NO (f) go to #14.]


    12. How many FTEs are devoted to VIP communication as a primary role?  Please note that a full time individual can serve multiple roles, but his or her time cannot add up to more than 1.00 FTE. For example, if you already reported that one person is 1.00 FTE equivalent as programs/ interventions, you cannot report this same person as one FTE communications.
    a. 0.0 FTE
    b. 0.01-0.25 FTE
    c. 0.26-0.50 FTE
    d. 0.51-0.75 FTE
    e. 0.76-0.99 FTE
    f. 1.0, or equivalent to one FTE
    g. More than 1.0, or equivalent to more than one FTE

    13. What type of training does the communications staff have? If you have more than one person devoted to this role, please provide the highest level of training attained by any person in this role.
        a. Graduate degree that included training in health communication
        b. Other graduate degree (please explain)
        c. Undergraduate degree (please explain) 


    14. Does your VIP program have access to staff support for policy work?
        a. Yes, within the VIP program
        b. Yes, within the state health department
        c. Yes, by consultant
        d. Yes, by Injury Control Research Center or other academic center 
        e. Yes, other (please specify)
        f. No

[If YES (a-e) go to #15  If NO (f) go to #17.]

    15. How many FTEs are devoted to VIP policy work as a primary role?  Please note that a full time individual can serve multiple roles, but his or her time cannot add up to more than 1.00 FTE. For example, if you already reported that one person is 1.00 FTE equivalent as programs/ interventions, you cannot report this same person as one FTE policy work. 
        a. 0.0 FTE
        b. 0.01-0.25 FTE
        c. 0.26-0.50 FTE
        d. 0.51-0.75 FTE
        e. 0.76-0.99 FTE
        f. 1.0, or equivalent to one FTE
        g. More than 1.0, or equivalent to more than one FTE

    16. What type of training does the policy staff have? If you have more than one person devoted to this role, please provide the highest level of training attained by any person in this role.
    a. Graduate degree that included training in health policy, government, political science
    b. Other graduate degree (please explain)
    c. Undergraduate degree (please explain) 


    17. Does your VIP program have access to staff support for programs/interventions?
    a. Yes, within the VIP program
    b. Yes, within the state health department
    c. Yes, by consultant
    d. Yes, by Injury Control Research Center or other academic center
    e. Yes, other (please specify)
    f. No

[If YES (a-e) go to #18. If NO (f) go to #20.]

    18. How many FTEs are devoted to VIP programs/interventions as a primary role? Please note that a full time individual can serve multiple roles, but his or her time cannot add up to more than 1.00 FTE. For example, if you already reported that one person is 1.00 FTE equivalent as communications, you cannot report this same person as one FTE programs/interventions.
        a. 0.0 FTE
        b. 0.01-0.25 FTE
        c. 0.26-0.50 FTE
        d. 0.51-0.75 FTE
        e. 0.76-0.99 FTE
        f. 1.0, or equivalent to one FTE
        g. More than 1.0, or equivalent to more than one FTE

    19. What type of training does the programs/interventions staff have? If you have more than one person devoted to this role, please provide the highest level of training attained by any person in this role.
    a. Graduate degree that included training in public health program implementation/behavioral sciences 
    b. Other graduate degree (please explain)
    c. Undergraduate degree (please explain)


    II. Infrastructure: Funding
 
    20. Please tell me about plans that are currently in place to sustain your VIP program’s efforts. Is the diversification of funding sources considered a strategy for sustainability?  If so, how?



    III. Infrastructure: Health Department Health Plan



    IV. Surveillance: Uses of Core Datasets


    21. Considering all of the datasets you have access to, in which of the following ways do you use surveillance data? (Check all that apply.)

YES
NO
    a. To inform policy
1
0
    b. To determine the effectiveness of programs
1
0
    c. To do cost analysis
1
0
    d. To inform decisions about planning injury and violence prevention initiatives
1
0

    22. Do you have a systematic way of selecting your priorities using surveillance data?   
        a. YES
        b. NO


    23. Which of these do you use when setting priorities? [select all that apply]
        a. High morbidity rates 
        b. High mortality rates
        c. Cost of injury
        d. Disparities across population groups
        e. Trend analysis 
        f. Other



    V. Surveillance: Dissemination of Surveillance Data

    24. If your program developed data reports or summaries, what types of reports or summaries were produced?  (Check all that apply) 
        a. Fact sheets for the public and/or policy makers
        b. Frequencies/Descriptive  data about injury problems 
        c. Narratives interpreting data
        d. Narratives outlining case reports about injured individuals 
        e. Publications  in peer-reviewed journals
        f. Presentations at conferences and workshops
        g. Posters at conferences and workshops
        h. Cost of injury reports
        i. Disparities among population groups or regions
        j. Reports with analytic measures (for example, Odds Ratio, Confidence Intervals, regression analyses)
        k. Regression/Trend Analysis 

    25. Were these reports disseminated?
        a. YES [Go to #32.]
        b. NO [Go to #35.]

    26. To whom were these reports disseminated? (Check all that apply.)
    a. ICRCs or other academic centers 
    b. Local public health depts.
    c. Through peer-reviewed publications
    d. VIP programs in other states
    e. ICPG members
    f. State health dept leadership
    g. Other stakeholders

    27. For reports distributed…

YES
NO
        a. Was there any discussion with these partners/stakeholders about the reports?
1
0
        b. Were any next steps/action items identified from the reports?
1
0


    28. If next steps were identified, please explain.


    VI. Strategies

Repeat Question 35 for each BIC focus area {$FOCUSAREA1-5}

    29. Please let me know if this list is complete and accurate of your strategies for {$FOCUSAREA1-5} in Year 1:
    • {$FOCUSAREA1-5_STRATEGY1}
    • {$FOCUSAREA1-5_STRATEGY2}
    • {$FOCUSAREA1-5_STRATEGY3}
    • {$FOCUSAREA1-5_STRATEGY4}
    • {$FOCUSAREA1-5_STRATEGY5}
    • {$FOCUSAREA1-5_STRATEGY6}
    a. YES, this is a complete and accurate list.
    b. NO, this is not a complete list: [Go to i]
            i. If this is not a complete list, please list the strategies that are not represented in the list above. Also note strategies from the list above that you are no longer implementing and should be deleted from the list.


    VII. Evaluation: Uses Evaluation Findings 
    VIII. Evaluation: Disseminates Evaluation Findings 
Repeat Questions 36-44 for each BIC focus area {$FOCUSAREA1-5}
Here are is the complete list of strategies for {$FOCUSAREA1-5} in Year 1:
    • {$FOCUSAREA1-5_STRATEGY1}
    • {$FOCUSAREA1-5_STRATEGY2}
    • {$FOCUSAREA1-5_STRATEGY3}
    • {$FOCUSAREA1-5_STRATEGY4}
    • {$FOCUSAREA1-5_STRATEGY5}
    • {$FOCUSAREA1-5_STRATEGY6}
    • {$FOCUSAREA1-5_STRATEGY(Q37i)}


    30. Did any evaluation findings result in policy/programmatic improvements within {$FOCUSAREA1-5}? 
        a. We reviewed evaluation findings AND made policy/programmatic changes
        b. We reviewed evaluation findings, BUT DID NOT make policy/programmatic changes
        c. We DID NOT review evaluation findings for policy/programmatic changes


    31. If YES, What types of evaluation reports or summaries were produced?  (Check all that apply)
            a. Summary reports including data and narrative information
            b. Final report to funder
            c. Brief summary report in a newsletter/regular communication
            d. Present evaluation findings during webinars/group conference calls
            e. Publications in peer-reviewed journals
            f. Presentations at conferences and workshops
            g. Posters at conferences and workshops
            h. Other: please specify


    32. Were any evaluation reports or summaries disseminated? 
    a. YES [Go to #42.]
    b. NO [Go to #45.]

    33. To whom were these reports distributed? 
        a. ICRCs or other academic centers
        b. Local public health depts.
        c. Through peer-reviewed publications
        d. VIP programs in other states
        e. ICPG members
        f. State health dept leadership
        g. Other stakeholders
        h. Webinar/conference call attendants
        i. Conference attendants

    34. For reports distributed…

YES
NO
    a. Was there any discussion with these partners/stakeholders about the reports?
1
0
    b. Were any next steps/action items identified from the reports?
1
0
[If YES, go to #44. If NO, go to #45.]

    35. If yes, please explain. 



    IX. Collaboration

We are interested to know what other partners may have provided resources – either financial or in-kind -- to assist you in promoting or implementing work in each of your BIC focus areas. Please focus on partners that enable you to do things you would not have been able to do on your own, and/or significantly expanded the reach of your program.  

Repeat Questions 45-48 for each BIC focus area {$FOCUSAREA1-5}

    36. Please let me know if this list is complete and representative of your collaborations and partnerships for {$FOCUSAREA1-5} in Year 1:
    • {$FOCUSAREA1-5_PARTNER1}
    • {$FOCUSAREA1-5_PARTNER2}
    • {$FOCUSAREA1-5_PARTNER3}
    • {$FOCUSAREA1-5_PARTNER4}
    • {$FOCUSAREA1-5_PARTNER5}

    • {$FOCUSAREA1-5_PARTNER6}
    • {$FOCUSAREA1-5_PARTNER7}
    • {$FOCUSAREA1-5_PARTNER8}
    • {$FOCUSAREA1-5_PARTNER9}
    • {$FOCUSAREA1-5_PARTNER10}

    • {$FOCUSAREA1-5_PARTNER11}
    • {$FOCUSAREA1-5_PARTNER12}
    • {$FOCUSAREA1-5_PARTNER13}
    • {$FOCUSAREA1-5_PARTNER14}
    • {$FOCUSAREA1-5_PARTNER15}
        a. YES, this is a complete list. [Go to # 46.]
        b. NO, this is not a complete list: [Go to i]
            i. If this is not a complete list, please enter in the name of the partnerships/collaboration that are not represented in the list above. Also note here if one of the partners listed above should be removed from the list.
Additional Partners

Partners to be Removed


    37. Still thinking about these organizations with which you partnered for your {$FOCUSAREA1-5}, tell us what type of assistance partner organizations provided. Please select all that apply. 

YES
NO
    a. Cash support (i.e. leveraging funds)
1
0
    b. Staff time for planning or implementing initiative
1
0
    c. Loan of facilities or vehicles or equipment
1
0
    d. Publicity through mailings, listserv
1
0
    e. Safety equipment to give away (e.g., smoke alarms, gun locks)
1
0
    f. Access to experts for training staff
1
0
    g. Access to experts for direct intervention with participants
1
0
    h. Contacts with other partners for fundraising efforts
1
0
    i. Contacts with other partners for advocacy efforts
1
0
    j. Printing materials, making supplies, or structures
1
0
    k. Making data available for planning or evaluation
1
0
    l. Assisting with data analysis for planning or evaluation
1
0
    m. Assisting with disseminating results
1
0
    n. Provides access to target population
1
0
    o. Other (specify):
1
0
    p. Other (specify):
1
0
    q. Other (specify):
1
0

    38. Considering all the resources (funding and other resources) needed for {$FOCUSAREA1-5}, please select the description from the list below that most accurately describes your work with partners for this focus area: (Choose one)
    a. The VIP program is the primary program implementer
    b. The VIP program and its partners are equal collaborators in program implementation
    c. The partners are the primary program implementers

    39. Was the VIP program a pass-through organization for funding to implement work in {$FOCUSAREA1-5}? 
        a. YES
        b. NO

<End of survey.>