Worksheet for Identifying Site Visit Interviews (Private Sector)

Form Approved

OMB No.: 0920-xxxx

Exp. Date: mm/dd/yyyy

Instructions for Identifying Interviewees

Public reporting burden of this collection of information is estimated to average 1 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: OMB 0920-XXXX

The purpose of this worksheet is to determine, in advance, individuals who could be interviewed during the site visit. Please use this form to identify people who are responsible for the intervention-related tasks about which we are interested in learning. Because every organizations uses its own names, terms, and arrangements, information on the tables will help you to be clear about the types of persons with whom we would like to talk.

Please return the Suggested Interviewees Form to Revae Downey at Revae [email protected] by [insert date].

After you have returned the form, an ICF International representative will contact you to confirm who is to be interviewed. We will use the list of possible interviewees you provide to finalize the number and schedule of interviews that the site visitors will conduct during the visit.

• Please provide the title, name, and intervention involvement for each suggested interviewee as indicated for each of the categories listed.

• Please return the form to Revae Downey via e-mail at Revae [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 ensure that the appropriate individuals have been identified for the interviews.

• After the telephone review and revision of the the schedule, if need be, an ICF International representative will provide you with instructions and a template to use when confirming each of the selected persons to be interviewed, as well as the time and location.

Worksheet for identifying site visit interviews for

[Insert title of organization]

The purpose of this worksheet is to identify relevant individuals involved with your Young Breast Cancer Survivor (YBCS) intervention and to note how they are involved. Please list the names of the persons involved in the design, delivery, and/or evaluation of the intervention, along with their titles and the main activities in which they are involved.

Program Director(s) or Principal Investigator: Those persons responsible for leading the intervention. Program Director/Principal Investigators oversee the program and monitor its implementation. Time Required per Interview: 2 Hours
Title/Position	Name	Main Intervention Involvement
Program Coordinator/Manager(s): Those persons responsible for managing the day-to-day implementation of the intervention. Program Coordinators/Managers provide managerial oversight for the program and staff. Time Required per Interview: 1 Hour
Title/Position	Name	Main Intervention Involvement
Program Staff: Those persons who are employed by the organization and are responsible for intervention-related tasks. Examples of intervention staff include, but are not limited to, Patient Navigators, Nurse Coordinators, Data Managers, Recruitment Coordinators, Workshop Facilitators and Health Care Providers. Time Required per Interview: 1 Hour
Title/Position	Name	Main Intervention Involvement
Program Partners: Those persons and organizations associated with intervention 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 your YBCS intervention is actively working on integrating, and community organizations. Time Required per Interview: 1 Hour
Title/Position	Name	Main Intervention Involvement