BIC Capacity Indicator Questionnaire

Attachment F – Core VIPP Evaluation

Form Approved
OMB No. 0920-0916
Exp. Date:
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suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333; Attn: PRA
(0920-0916).

FFY2013 BIC Capacity Indicator Questionnaire
I. Infrastructure: Workforce
State IVP Program Director
1.In FFY 2013, did the state IVP program have a director?
1. Yes, Full-time (e.g., 40+ hours a week) [Go to #2.]
2. Yes, Part-time (e.g., less than 40 hours a week) [Go to #2.]
3. NO [Go to #6.]

2. Now we would like to ask about the work experience of the state IVP program director. How many years and months has the state IVP
program director...
Year(s)

Month(s) Enter zero (0) if you are only entering years.

worked in his or her current position?
worked in the field of injury and violence prevention?
worked in the field of public health?
3. What was the highest level of education completed by the state IVP program director? (select one)
1. High School Diploma
2. Associate’s Degree
3. Bachelor’s degree
4. Graduate
5. Don’t Know
4.What injury-specific trainings and/or certifications has the state IVP program director completed? (Check all that apply).
1. No trainings/certifications: The state IVP program director has not completed any injury-specific trainings and/or
certifications
2. At least one graduate-level course in injury and/or violence prevention
3. A graduate-level training program in injury and/or violence prevention (e.g., University of Washington Graduate Certificate in
Global Injury and Violence Prevention, University of Iowa Occupational Injury Prevention Program, MS/MPH/PhD with a
focus on an area of injury prevention, etc.)
4. A university-affiliated training program/fellowship, (e.g., Johns Hopkins Summer Institute, Preventing Violence through
Education, Networking, and Technical Assistance (PREVENT) training / University of North Carolina, etc.)
5. Training program/fellowship sponsored by a professional association (e.g., Safe States Alliance “Injury Prevention 101”
Self-Study Training, etc.)
6. Training program/fellowship sponsored by a federal government agency (e.g. Indian Health Service Injury Prevention Courses,
etc.)
7. The World Health Organization/Education Development Center TEACH IVP E-Learning Curriculum (one or more lessons)
8. Child Passenger Safety Technician
9. EMS professional (e.g., EMT, Paramedic, etc.)
10. Certified Health Education Specialist (CHES)
11. Certified in Public Health (CPH)
12. Registered Nurse (RN)
13. Please explain:

State IVP Program Staff
5A. In FFY 2013, how many full time equivalents (FTEs) were staffed within the state IVP program
5B. In FFY 2013, how many FTEs were directly supported by CDC/NCIPC Core VIPP Base Integration Component (BIC)?
Please enter the number of FTEs by staff roles.
IMPORTANT NOTE: For an FTE calculator that will help you determine your total number of FTEs, copy/paste the following URL into a new internet
browser, www.safestates.org/associations/5805/files/FTE%20Calculator.xls. Calculate part-time positions (partial FTEs) using the formula found here.
For example, if you have a total of two (2) full-time staff positions at 40 hours/week (equal to 2 FTEs) and one 20 hour/week staff position (equal to one
0.5 FTE), the correct response for your total number of FTEs would be 2.5.Please enter 0.00, if the state IVP program did not have access to a primary
role. All cells must have a numerical value.

5A.
5B.
FTEs within the state FTEs Support by BIC
IVP Program
Funding
Coalition building & coordination staff
Communications staff
Data analysis staff (e.g., epidemiologist, statistician, etc.)
Evaluation staff
Management staff
Policy staff
Program/Intervention staff
Support and administrative staff
Technical assistance & training staff
Other

6. In FFY 2013, were individuals outside of the state IVP program used to fill staff roles? (Check all that apply)
Yes, within the
state health
department
Coalition building & coordination staff
Communications staff
Data analysis staff (e.g., epidemiologist, statistician, etc.)
Evaluation staff
Management staff
Policy staff
Program/Intervention staff
Support and administrative staff
Technical assistance & training staff
Other

Yes, by
consultant

Yes, by Injury
Control
Research
Center (ICRC)

No, did not use

II. Infrastructure: Funding
In this section you’ll be asked about the state IVP program funding sources, both current and past. Please be sure to have your records
accessible before you begin this section.
Below is a list of funding sources you provided in the FFY 2011 State of the States Finance and Personnel Report.
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2}${custom13}${custom14}${custom15}${custom16}${custom17}${custom18}

7A. Please select all the funding sources the state IVP program had in FFY 2013 (October 1, 2011 – September 30, 2013).
1. State General Revenue
20. HRSA/MCHB – Title V Block Grant
2. Dedicated State Funding Stream (e.g., fines and fees)
21. HRSA/MCHB – Emergency Medical Services for
3. State Highway Safety Office (e.g., Safe Routes to School)
Children (EMSC)
4. Other State Funding 1
22. National Highway Traffic Safety Administration
5. Other State Funding 2
(NHTSA) CODES
6. Other State Funding 3
23. National Highway Traffic Safety Administration
7. CDC/NCIPC Core VIPP Base Integration Component
(NHTSA) Other
(BIC)
24. Substance Abuse and Mental Health Services
8. CDC/NCIPC Core VIPP Regional Network Leader
Administration (SAMHSA) Campus Suicide Prevention
(RNL)
Grants
9. CDC/NCIPC Core VIPP Surveillance Quality
25. Substance Abuse and Mental Health Services
Improvement (SQI)
Administration (SAMHSA) State and Tribal Youth
10. CDC/NCIPC Core VIPP Motor Vehicle Injury
Suicide Prevention Grants
Prevention
26. U.S. Department of Justice
11. CDC/NCIPC Core VIPP Falls Among Older Adults
27. U.S. Department of Transportation (Federal, not through
12. CDC/NCIPC National Violent Death Reporting System
the state DOT or State Highway Safety Office)
(NVDRS)
28. Other Federal Funding 1
13. CDC/NCIPC – Rape Prevention and Education (RPE)
29. Other Federal Funding 2
14. CDC/NCIPC Domestic Violence Prevention
30. Other Federal Funding 3
Enhancement and Leadership Through Alliances
31. Corporate/Private
(DELTA)
32. Foundation
15. CDC/NCIPC Residential Fire-related Injury Prevention
33. Nonprofit Organizations (i.e., Safe Kids, Public Health
Program
Institutes, etc)
16. CDC – Preventive Health and Health Services (PHHS)
34. Universities
Block Grant
35. Other 1
17. CDC – Communities Putting Prevention to Work
36. Other 2
18. Consumer Product Safety Commission (CPSC)
37. Other 3
19. Federal Emergency Management Agency (FEMA)

7B. Please specify the name of other funding sources the state IVP program received.
Other State Funding 1
Other State Funding 2
Other State Funding 3
Other Federal Funding 1
Other Federal Funding 2
Other Federal Funding 3
Other 1
Other 2
Other 3

III. Infrastructure: Health Department Plan
Now we’d like to know if your state health department has a strategic plan that includes IVP goals and objectives and/or topics. A state
health department strategic plan includes multiple departments and units within the state health department; this plan also includes
multiple health issues that may include chronic diseases, infectious disease, injury, violence, and more. This question is NOT asking
you to report on strategic plans solely developed and implemented by the state IVP program.

8.Did your state health department have a strategic plan in FFY 2013?
1. Yes, there was a completed strategic plan
2. Yes, but the plan was in development or was incomplete as of FFY 2013.
3. No, there was not a strategic plan [Go to #11.]
4. Don’t Know [Go to #11.]

9. Were injury and/or violence prevention topics specifically included in the state health department strategic plan?
1. Yes, injury and/or violence prevention topics were specifically included in the plan.
2. No, injury and/or violence prevention topics were NOT specifically included in the plan. [Go to #11.]
3. Don’t Know [Go to #11.]

10. Please select the option that best describes which specific injury and violence prevention topics were included within the state
health department strategic plan.
1. All Terrain Vehicle (ATV) injury
9. Homicide
17. School-based injury
2. Child abuse/neglect
10. Mass trauma/disaster-related
18. Sexual assault/rape
3. Child passenger safety
11. Motor vehicle injury
19. Spinal cord injury (SCI)
4. Domestic/intimate partner
12. Motorcycle/motorized scooter
20. Submersion injuries/drowning
violence
injury
21. Suicide/self-inflicted
5. Elder Abuse
13. Occupational injury
22. Suicide attempts
6. Fall injuries
14. Pedestrian injury
23. Teen Dating Violence
7. Fire and burns injury
15. Poisoning
24. Traumatic brain injury (TBI)
8. Firearm injury
16. Rural/agricultural injury
25. Other

IV. Surveillance: Access to and Use of Core Datasets
CAUTION: Once you click “Continue” to submit your answer(s) the question below, you will NOT be able to change your response.
The answer(s) you select for this question will control the response options provided in subsequent questions. Therefore, please take care
and be certain when selecting your response(s), as you will NOT be able to change your answer(s) after this point.
This section asks about your program’s access to and use of various datasets.

11. What datasets did the state IVP program have access to in FFY 2013?
1. NONE
2. Addiction and Mental Health Surveys
13.
3. Behavioral Risk Factor Surveillance System (BRFSS)
14.
4. Child Death Review (CDR)
15.
5. Emergency Department (ED) data
16.
6. Emergency Medical Services (EMS) data
7. Fatality Analysis Reporting System (FARS)
17.
8. Hospital Discharge Data (HDD)
18.
9. Medical Examiner
19.
10. Motor Vehicle Traffic Records
20.
11. National Emergency Medical Services Information
System (NEMSIS)
21.
12. National Intimate Partner and Sexual Violence Survey
22.

(NISVS)
National Occupant Protection Use Survey (NOPUS)
National Violent Death Reporting System (NVDRS)
Nationwide Emergency Department Sample (NEDS)
Pregnancy Risk Assessment Monitoring System
(PRAMS)
Prescription Drug Monitoring Program
Uniform Crime Reporting System (UCR)
Vital Records
Web-based Injury Statistics Query and Reporting System
(WISQARS)
Youth Risk Behavior Surveillance System (YRBSS)
Other

12. How did the state IVP program use each of the following datasets? (Check all that apply)
To identify
To identify a
To identify specific To identify risk
topic-specific geographic region population groups and/or protective
injury and where an injury or that are affected by factors associated
violence
violence issue is an injury or violence with an injury or
issues
occurring
issue
violence issue
Addiction and Mental Health Surveys
Behavioral Risk Factor Surveillance System (BRFSS)
Child Death Review (CDR)
Emergency Department (ED) data
Emergency Medical Services (EMS) data
Fatality Analysis Reporting System (FARS)
Hospital Discharge Data (HDD)
Medical Examiner
Motor Vehicle Traffic Records
National Emergency Medical Services Information System
(NEMSIS)
National Intimate Partner and Sexual Violence Survey (NISVS)
National Occupant Protection Use Survey (NOPUS)
National Violent Death Reporting System (NVDRS)
Nationwide Emergency Department Sample (NEDS)
Pregnancy Risk Assessment Monitoring System (PRAMS)
Prescription Drug Monitoring Program
Uniform Crime Reporting System (UCR)
Vital Records
Web-based Injury Statistics Query and Reporting System

(WISQARS)
Youth Risk Behavior Surveillance System (YRBSS)

13. How did the state IVP program use surveillance data to address the FFY 2013 BIC focus areas? (Check all that apply)
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}
To inform program or policy development
To track/monitor program or policy implementation
To inform evaluations of programs or policies
To assess costs of injury problems
To analyze cost implications of interventions
(program or policy)

V. Surveillance: Dissemination of Surveillance Data
14. Did the state IVP program use surveillance data of any kind to produce any of the following? (Check all that apply).
1. The state IVP program did NOT develop any data reports or summaries. [Go to #17.]
2. Fact sheets about injury generally or specific injury problems for the public and/or policy makers
3. Presentations/posters at conferences and workshops
4. Publications in peer-reviewed journals
5. Publications in print media (e.g., newspapers)
6. Technical reports
7. Other
15. To whom were the reports and/or summaries disseminated? (Check all that apply.)
1. Reports and/or summaries were NOT disseminated [Go to #17.]
2. Federal agencies
3. Injury Community Planning Group (ICPG) members
4. Injury Control Research Centers (ICRCs) or other academic centers
5. IVP programs in other states
6. Local public health departments
7. Non-governmental agencies
8. Other state agencies
9. Other state health department divisions
10. To subscribers of peer-reviewed publications
11. Other stakeholders

16. Were any next steps/action items identified in the reports and/or summaries produced?
1. NO
2. YES

The next sections of the questionnaire will ask about evaluation activities and partnerships within each of the BIC Focus Areas for your
state.

VI. Evaluation: Uses Evaluation Findings
VII. Evaluation: Disseminates Evaluation Findings
17. In FFY 2013, what types of evaluations did the state IVP program conduct for any strategy related to ${custom19}?
The state IVP
The state IVP program was An evaluation plan for this The state IVP program did
program completed
in the process of
type was developed, but NOT have an evaluation plan
this evaluation type in completing this evaluation evaluation activities were for this type in FFY 2013
FFY 2013.
type in FFY 2013.
not started in FFY 2013.
Outcome evaluation
Process evaluation
Formative evaluation
18. For the outcome evaluations completed or that were in the process of being completed in FFY 2013, did any evaluation findings
result in policy/programmatic improvements within ${custom19}?
1. YES, staff reviewed the evaluation findings AND made policy/programmatic changes
2. Staff reviewed evaluation findings, BUT DID NOT make policy/programmatic changes
3. NO, staff DID NOT review evaluation findings or make any policy/programmatic changes

19. For the outcome evaluations completed or are in the process of being completed, what types of methodologies or approaches did the
state IVP program use for ${custom19}? (Check all that apply)
1. Surveys/Questionnaires
2. Experimental studies (e.g., RCT)
3. Quasi-experimental studies (e.g., Time Series/Analysis)
4. Interviews
5. Focus Groups
6. Participant Observation
7. Document Reviews
8. Other (please explain)

20. In FFY 2013, what types of evaluation reports and/or summaries were produced? (Check all that apply)
1. The state IVP program did NOT develop any evaluation
6. Posters at conferences and workshops
reports or summaries [Go to #23.]
7. Presentations at conferences and workshops
2. Article in a newsletter and/or regular communication
8. Publications in peer-reviewed journals
3. Final report to funder
9. Summary reports including data and narrative
4. Internal or informal report
information
5. Presentation during webinar/conference call
10. Other: please specify

21. To whom were the reports and/or summaries disseminated? (Check all that apply.)
1. Reports and/or summaries were NOT disseminated
6. Local public health departments
[Go to #23.]
7. Non-governmental agencies
2. Federal agencies
8. Other state agencies
3. Injury Community Planning Group (ICPG) members
9. Other state health department divisions
4. Injury Control Research Centers (ICRCs) or other
10. Through peer-reviewed publications
academic centers
11. Other (Please specify)
5. IVP programs in other states

22. Were any next steps/action items identified from the reports?

1. NO
2. YES

VIII. Collaboration
Below is a list of partners that were included in your most recent Annual Progress Report (APR) to address ${custom19}.
${custom26}${custom27}${custom28}${custom29}${custom30}${custom31}${custom32}${custom33}${custom34}${custom35}$
{custom36}${custom37}${custom38}${custom39}${custom40}

23. Please review this list and confirm if the list is complete and representative of your partnerships for this Focus Area in FFY 2013:
1. YES, this is a complete list. [Go to # 24.]
2. NO, this is not a complete list: [Go to i]
i. Please enter in the name of the partners that are not represented in the list above. Also, please note here if one or more of
the partners listed above should be removed from the list.
Additional Partners

Partners to be Removed

24. Thinking about all of your partners for ${custom19}, please list up to three (3) that would be considered key or most important
partners in FFY 2013.
Partner #1:
Partner #2:
Partner #3:

25.
Still thinking about the key partners identified in the previous question that supported your work in ${custom19}, please tell
us what types of assistance your partner organizations provided in FFY 2013. (Check all that apply)
Partner #1 Partner #2
Provided funding to support state IVP staff for program planning, implementation, and/or
evaluation
Provided funding to support state IVP staff for data collection and/or analysis
Dedicated staff (in-kind) to assist with program planning/implementation
Loaned or purchased facilities or meeting space
Provided safety equipment for dissemination (e.g., smoke alarms, gun locks)
Provided access to key target population(s)
Provided contacts with other partners for fundraising efforts
Conducted programs/interventions for target population(s)
Provided access to experts to train/support state IVP staff
Collaborated on policy (e.g., policy development, policy implementation, advocacy, etc.)
Provided access to a dataset
Assisted with implementing evaluation activities (plan development, data collection, and/or data
analysis)
Assisted with disseminating evaluation results
Assisted with communication activities (e.g., dissemination/promotion of activities through
mailings/listservs, development of printed materials, etc.)
Other

Partner #3

26. Thinking about the time and resources necessary to work in the focus area of ${custom19}, please select the description from the
list below that most accurately describes your work with partners for this Focus Area: (Choose one)
1. The state IVP program is the primary program implementer
2. The state IVP program and one or more of its partners are equal collaborators in program implementation
3. One or more partners are the primary program implementers