Awardee Administrators Program Survey

ATTACHMENT C1

Program Survey

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WISEWOMAN Program Survey

Public Burden Statement:   Public reporting burden of this collection of information is estimated to average 60 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, and a person is not required to respond to a collection of information unless it displays a currently valid Office of Management and Budget control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Sections:

A	PROGRAM BACKGROUND AND MANAGEMENT
B	CLINICAL SERVICES
C	HEALTH BEHAVIORAL SUPPORT
D	MONITORING AND EVALUATION
E	ADDITIONAL FEEDBACK

Administrative Notes:

• The instrument is designed in an editable PDF format, estimated at 60 minutes in length.

• Skip patterns, where applicable, will be specified next to response options with arrows.

• The survey will be administered in English only.

• The survey will be administered two times – once in Year 2 and once in Year 4. Items that refer to the program year are noted in this instrument using brackets and gray highlighting (e.g., [2 or 4]). We will ultimately create two versions of the survey based on year of administration.

• Items that allow multiple responses have the instruction to “Select all that apply,” and items allowing only a single response have the instruction to “Select one only”.

INTRODUCTION AND CONSENT

Form Approved

OMB Control No: XXXXX

Expiration Date:  XXXXXX

Since 1995, the Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program has provided women with services to support prevention, management, and treatment of cardiovascular disease. Your input on the experiences of your WISEWOMAN program enable us to better understand how programs are supporting women and the most effective ways that programs are doing so.

This survey should take approximately 60 minutes to complete. Participation in the survey is completely voluntary and you may choose to skip any question. Your responses will be kept private and used only for research purposes. The evaluation will not identify individuals or organizations in its reports to the Centers for Disease Control and Prevention (CDC). Your answers will not have any impact on the funding or any other support that your WISEWOMAN program and agency may receive.

To expedite completion of the survey, we recommend that you have your work plan, budget, annual reports, and other program and policy documents (such as, provider contracts and requirements) easily accessible as you go through the survey.

When you have finished responding, save and email the completed survey to [email protected]

If you have any questions about the survey, please do not hesitate to contact Katie Morrison at (202) 264-3450 or [email protected]. If you have questions about the research, contact So O’Neil at Mathematica Policy Research. You can reach So by calling (617) 301-8975 or emailing [email protected]. If you have questions about your rights as a research participant, contact Kate Marchand at the IRB Office by calling (617) 243-3924 or emailing [email protected].

Thank you for participating in this survey. By completing the survey and submitting your responses, you are confirming that you understand the information you provide will be kept private, used only for research purposes, and that your answers will be combined with the responses of other grantees so that no individuals or programs are identified. Please retain a copy of this study information for your future reference.

OMB Control No. XXXX-XXXX

Public Burden Statement: Public reporting burden of this collection of information is estimated to average 60 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, and a person is not required to respond to a collection of information unless it displays a currently valid Office of Management and Budget control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

SECTION A. PROGRAM BACKGROUND AND MANAGEMENT

The first section contains general questions about your WISEWOMAN program, including questions about:

• Program objectives

• Professional development

• Grants management and budgeting

• Clinical service contracts and agreements, and

• Program eligibility and recruitment.

Program Objectives

A1. Currently, what are your specific program’s objectives?

Please describe the specific objectives your program hopes to accomplish in your state or tribal area. These objectives may include those discussed with your state health department and tribal organization and could be related to specific populations, initiatives or interventions, or disease areas.

Professional Development

The next questions are about professional development opportunities offered to staff through WISEWOMAN funding.

A2. Does your program provide any professional development opportunities for any staff funded in part or full by WISEWOMAN (including internal staff, providers, and other contractors)?

Select one only

1  Yes

2  No GO TO A6

A3. Below is a list of broad topics that some WISEWOMAN grantees address through staff professional development. Since July 2013, how frequently has your program addressed each of the following topics through professional development, if at all?

Include professional development offered to any staff who are funded in part or full by WISEWOMAN (including internal staff, providers, and other contractors).

Select one per row

	Never	Less than once per year	1-2 times per year	More than 2 times per year
a. WISEWOMAN orientation and program basics	0 	1 	2 	3 
b. Identification of abnormals and alerts	0 	1 	2 	3 
c. Proper clinical measurement technique	0 	1 	2 	3 
d. Patient-centered risk reduction counseling	0 	1 	2 	3 
e. WISEWOMAN data monitoring/ tracking system	0 	1 	2 	3 
f. Motivational interviewing	0 	1 	2 	3 
g. Health coaching	0 	1 	2 	3 
h. Data quality and improvement techniques	0 	1 	2 	3 
i. Other professional development opportunities	0 	1 	2 	3 
Specify:
j. Other professional development opportunities	0 	1 	2 	3 
Specify:

A4. Thinking of the topics on which your program provides professional development, has your program offered any of the following types of professional development to WISEWOMAN staff since July 2013?

Select one per row

	Yes	No
a. In-person trainings (led by internal staff)	1 	0 
b. In-person trainings (led by external/ hired staff)	1 	0 
c. Joint trainings with other organizations in the community	1 	0 
d. National and regional meetings (for example, on heart disease, public health, or other relevant topics)	1 	0 
e. Group trainings over the telephone/ webinars	1 	0 
f. Other way(s) of conducting professional development	1 	0 
Specify:

A5. Since the beginning of the current funding cycle (that is, since July 2013), which of the following groups of staff have been offered each type of professional development opportunity?

Please include any external staff with whom your program might contract.

Select all that apply per row

	Program director and manager	Data manage-ment staff	Evaluation staff	Lifestyle program staff	Health coaching (HC) staff	Clinical providers
a. In-person trainings (led by internal staff)	1 	2 	3 	4 	5 	6 
b. In-person trainings (led by external/ hired staff)	1 	2 	3 	4 	5 	6 
c. Joint trainings with other organizations in the community	1 	2 	3 	4 	5 	6 
d. National and regional meetings	1 	2 	3 	4 	5 	6 
e. Tele-conferences	1 	2 	3 	4 	5 	6 
f. Other type of professional development not listed above	1 	2 	3 	4 	5 	6 

Grants Management and Budget

The next questions are about your program’s budget and funding sources in program year [2 or 4].

A6. Thinking about your program’s total budget (including cash, in-kind support, and donated materials/ services), what percent of your funding used by WISEWOMAN comes from the following sources:

Please answer for program year [2 or 4].

	% FUNDING
a. From CDC WISEWOMAN?
b. From other federal funds (such as BCCEDP, Heart Disease and Stroke Prevention Program, or other federal programs)?
c. From some other source (such as American Heart Association or state matching funds)?
TOTAL	100%

A7. For each program activity listed below, does your program use funding from CDC WISEWOMAN to support the activity (either in part or in full)? Please answer for program year [2 or 4].

	Select one response per row
	Yes	No	Not Applicable, Program does not offer this service
a. Screening and medical evaluation	1 	0 	3 
b. Case management	1 	0 	3 
c. Risk reduction counseling (e.g., verbally reviewing screening results and health risk assessment)	1 	0 	3 
d. Healthy behavior support options (LSPs and HCs)	1 	0 	3 
e. Translation services for participants	1 	0 	3 
f. Transportation services for participants	1 	0 	3 
g. Printing forms and materials for participants	1 	0 	3 
h. Mailing hard copy forms to participants	1 	0 	3 
i. Other use of CDC funding	1 	0 	3 
Specify:

Clinical Service Contracts and Agreements

The next questions ask about the contracts or formal agreements that your program has with organizations to provide clinical services to participants.

A8. Of the clinical provider sites that serve WISEWOMAN participants, what percentage use electronic medical records (EMRs) for intake and tracking?

Select one only

1  100%

2  75 – 99%

3  50 – 74%

4  25 – 49%

5  1 – 24%

6  0%

A9. How does your organization ensure that clinical service providers follow program guidelines?

	Select one response per row
	Yes	No
a. Conduct site visits	1 	0 
b. Review MDE and other clinical data	1 	0 
c. Conduct trainings with clinical staff	1 	0 
d. Conduct audits	1 	0 
e. Chart reviews	1 	0 
f. Other way of ensuring that providers follow federal guidelines	1 	0 
Specify:

A10. What is the payment structure that your organization uses to pay for clinical services?

	Select one response per row
	Yes	No
a. Fee for service	1 	0 
b. Capitated per participant	1 	0 
c. Capitated by practice	1 	0 
d. Pay for performance	1 	0 
e. Bundled payment system	1 	0 
f. Don’t reimburse for clinical services	1 	0 
g. Other payment structure(s)	1 	0 
Specify:

A11. When does reimbursement for clinical services occur?

Select all that apply

1  Immediately after notification of the service delivery/submission of service data whether or not it is complete

2  A set amount of time after notification of service delivery/submission of data whether or not it is complete

3  After data are considered complete for a record

4  No set time period for reimbursement

Eligibility and Recruitment

The next questions are about your program’s eligibility requirements and recruitment strategies.

A12. In addition to WISEWOMAN eligibility criteria, what other criteria does your program use determine eligibility?

A13. How does your program (including internal staff, providers and/or other contractors) identify eligible participants?

	Select one response per row
	Yes	No
a. Review Breast and Cervical Cancer Early Detection Program (BCCEDP) list of women and follow-up with eligible individuals	1 	0 
b. Referrals from providers	1 	0 
c. Outreach into the community	1 	0 
d. Other method(s) for identifying eligible participants	1 	0 
Specify:

A14. When does your program determine whether a participant is eligible?

	Select one response per row
	Yes	No
a. Before office visit	1 	0 
b. During office visit	1 	0 
c. After office visit	1 	0 

SECTION B. CLINICAL SERVICES

The next section is about the types of clinical services that your program offers to WISEWOMAN participants and how your program delivers these services. Questions are split into four sub-sections:

• Team based care

• Screening protocols

• Risk reduction counseling, and

• Medication access

Team Based Care

B1. What percentage of your provider sites practice team-based care?

Team-based care is an intervention that incorporates a multidisciplinary team to improve the quality of cardiovascular-related care for patients. Team members provide process support and share responsibilities of care to complement the activities of the primary care provider.

Select one only

1  0 % GO TO B6

2  1 - 25 %

3  26 - 50 %

4  51 - 75 %

5  76 - 99 %

6  100 %

B2. In general, who makes up the health care delivery team for WISEWOMAN participants?

Select all that apply

1  Patient

2  Primary care doctor

3  Nurse

4  Nutritionist/dietician

5  Life style program coordinator

6  Pharmacist

7  Social worker(s)

8  Community health worker

9  Case manager

10  Other clinical staff

Specify:

11  Don’t know

B3. On average, how often do professionals on the health care delivery team with your program conduct the following activities?

Select one per row

	Daily	Weekly	Bi-Weekly	Monthly	Less than monthly	Don’t Know
a. Team meetings with patient present	1 	2 	3 	4 	5 	d 
b. Team meetings without patient	1 	2 	3 	4 	5 	d 
c. Chart review/medical record review	1 	2 	3 	4 	5 	d 
d. Referrals to other services	1 	2 	3 	4 	5 	d 
e. Provide patient education on self-management	1 	2 	3 	4 	5 	d 
f. Provide support on medication management	1 	2 	3 	4 	5 	d 

B4. How do members of the health care delivery team communicate about patients and coordinate care? Do they use…

	Select one response per row
	Yes	No	Don’t Know
a. A shared data system	1 	0 	d 
b. Email communication	1 	0 	d 
c. Phone communication	1 	0 	d 
d. In-person communication	1 	0 	d 
e. Sharing of hardcopy materials	1 	1 	0 
f. Meetings	1 	0 	d 
g. Some other form(s) of communication	1 	0 	d 
Specify:

Screening Protocols

The next questions are about protocols your program uses to conduct screenings related to blood pressure, weight, cholesterol, and diabetes/ glucose levels.

B5. How do your providers typically report blood pressure?

Select all that apply

1  Providers report the first blood pressure value taken

2  Providers report all blood pressure measurements as separate values

3  Provider report all blood pressure measures as an average

B6. In general, how much of a challenge do providers experience collecting and reporting two or more blood pressure measurements?

Select one only

1  Not a challenge

2  Somewhat of a challenge

3  A major challenge

B7. In general, do providers take participants’ waist measurements?

1  Yes

2  No

B7a. In general, do providers take participants’ hip measurements?

1  Yes

2  No

IF PROVIDERS GENERALLY TAKE PARTICIPANTS’ WAIST MEASUREMENTS (B7 = YES) AND/ OR

PARTICIPANTS’ HIP MEASUREMENTS (B7A = YES) CONTINUE TO B8.

IF PROVIDERS GENERALLY DO NOT TAKE WAIST MEASUREMENTS (B7= NO) OR HIP MEASUREMENTS (B7a = NO), SKIP TO B10.

B8. How much of a challenge do program staff experience in collecting accurate waist or hip measurements from participants?

Select one only

1  Not a challenge GO TO B10

2  Somewhat of a challenge

3  A major challenge

d  Don’t know

B9. Which of the following are challenges program staff have when collecting hip or waist measurements for participants?

Select all that apply

1  Lack of time to collect measurements during interactions with participants

2  Patient refusal or reluctance

3  Lack of staff knowledge about how to collect the measurements

4  Lack of place in data system to record all the measurements

5  Other barriers

Specify:

B10. When participants are referred to clinical services based on screening results, are they offered any of the following case management or health navigation services to facilitate the referral?

	Select one response per row
	Yes	No	Not Applicable
a. Transportation services (to and from appointments)	1 	0 	3 
b. Child care	1 	0 	3 
c. Translation services	1 	0 	3 
e. Financial assistance	1 	0 	3 
f. Enrollment in health insurance	1 	0 	3 
g. Other type(s) of service	1 	0 	3 
Specify:

B11. Does your program use community health workers to carry out any program activities?

Community health workers may also be known as lay health workers/ educators, community health advocates, community health outreach workers, or Promotores y Promotoras de Salud.

Select one only

1  Yes

2  No GO TO B13

B12. Are community health workers used to carry out any of the following case management and/or health navigation services to WISEWOMAN participants?

Community health workers may also be known as lay health workers/ educators, community health advocates, community health outreach workers, or Promotores y Promotoras de Salud.

	Select one response per row
	Yes	No	Not Applicable
a. Transportation services (to and from appointments)	1 	0 	3 
b. Child care	1 	0 	3 
c. Translation services	1 	0 	3 
d. Financial assistance	1 	0 	3 
e. Enrollment in health insurance	1 	0 	3 
f. Other type(s) of service	1 	0 	3 
Specify :

B13. How do program staff follow up with participants who are referred for clinical services?

	Select one response per row
	Yes	No
a. Telephone call	1 	0 
b. Email	1 	0 
c. Text messaging	1 	0 
d. Video communication (e.g. Skype, FaceTime)	1 	0 
e. Mail	1 	0 
f. Face to face at WISEWOMAN site	1 	0 
g. Face to face at another location	1 	0 
h. Other type(s) of follow-up not listed above	1 	0 
Specify:

B14. Does your program track any of the following metrics regarding clinical referrals for program participants based on the WISEWOMAN screening?

	Select one response per row
	Yes	No
a. Providers available for referrals	1 	0 
b. Number of referrals made	1 	0 
c. Number of referrals completed	1 	0 
d. Services provided during referrals	1 	0 
e. Diagnoses	1 	0 
f. Clinical outcomes	1 	0 
g. Other metric(s) for clinical referrals not listed above	1 	0 
Specify:

B15. Which of the following barriers make it difficult for program participants to attend clinical appointments?

If participants do not experience any barriers, please select “no” for each item.

	Select one response per row
	Yes	No
a. Lack of time	1 	0 
b. Lack of insurance coverage	1 	0 
c. Lack of access to clinical providers who are sensitive to participants' beliefs and values	1 	0 
d. Lack of transportation	1 	0 
e. Lack of child care	1 	0 
f. Substance abuse	1 	0 
g. Depression or other mental health conditions	1 	0 
h. Domestic/ intimate partner violence	1 	0 
i. Language barriers	1 	0 
j. Long waits for appointments with clinical providers	1 	0 
k. Difficulty scheduling appointments with clinical providers	1 	0 
l. Inconvenient provider office hours	1 	0 
m. Other barriers not listed above	1 	0 
Specify:

Risk Reduction Counseling

B16. In general, when do participants receive risk reduction counseling?

Select one only

1  At screening visit GO TO B18

2  After screening visit

3  A combination of at the screening visit and after the screening visit

B17. On average, how long is it between the date that participants start risk reduction counseling and when they complete risk reduction counseling?

Select one only

1  Completed on same day

2  One or two days later

3  Three to six days later

4  One week later

5  Two weeks later

6  Three weeks later

7  One month later

8  More than one month later

99  Other

Specify:

Medication Access

The next question is about what your WISEWOMAN program does to ensure participants’ access to affordable medication.

B18. Below is a list of strategies that some grantees use to ensure participants’ access to affordable medication. During the current funding cycle, which of these strategies has your program used?

	Select one response per row
	Yes	No
a. Require health care providers to assist women with accessing affordable medication	1 	0 
b. Provide staff orientation and training on useful sources/avenues for affordable medication	1 	0 
c. Maintain a database of useful resources and websites for affordable medication that providers can use	1 	0 
d. Offer a forum for providers or social service agencies to share resources and tips on accessing affordable medication	1 	0 
e. Reimburse providers for services related to helping patients access medication, such as submitting applications to pharmaceutical companies	1 	0 
f. Follow-up with providers to obtain a description of the process that will be used to ensure medication access	1 	0 
g. Conduct periodic audits to determine if participants who need medication resources were linked to these services	1 	0 
h. Conduct periodic participant surveys that include questions about medication access	1 	0 
i. Other strategies to ensure participant access to affordable medication	1 	0 
Specify:

SECTION C. HEALTH BEHAVIORAL SUPPORT

The next section is about health behavioral support that your WISEWOMAN program provides to participants. These questions will be divided into three sub-sections focusing on:

• Lifestyle programs

• Health coaching

• Other community-based resource referrals

Lifestyle Programs

The next questions are about Lifestyle Programs only.

C1. Which of the following criteria does your organization consider when referring participants to lifestyle programs?

Select all that apply

1  Participant risk level

2  Participant readiness to change

3  Accessibility of the resource (e.g., scheduling, location, hours of operation)

4  We refer all women to lifestyle programs GO TO C3

99  Priority goals identified

Specify:

C2. How does your program use readiness to change categories to determine participant eligibility for lifestyle programs?

For the readiness to change categories listed below, indicate whether a participant in the specified category would be eligible for lifestyle programs, would possibly be eligible for lifestyle programs, or would not be eligible for lifestyle programs?

	Select one response per row
	Eligible	Possibly eligible	Not eligible
a. Pre-contemplation	1 	2 	3 
b. Contemplation	1 	2 	3 
c. Preparation	1 	2 	3 
d. Action	1 	2 	3 
e. Maintenance	1 	2 	3 

C3. Does your program use any of the following methods to support completion of a Lifestyle Program? Select one per row

	Select one response per row
	Yes	No
a. Reminders by phone	1 	0 
b. Reminders by email	1 	0 
c. Provide incentives (e.g., coupons, prizes, gifts)	1 	0 
d. Provide child care for participants	1 	0 
e. Provide transportation for participants	1 	0 
f. Reimbursement of Lifestyle fees	1 	0 
g. Other methods to facilitate completion of referrals to Life style programs	1 	0 
Specify:

C4. How does your program track participation in Lifestyle Programs?

Select all that apply

1  Follow-up with LSP providers

2  Follow-up with participants

3  Use of an integrated electronic tracking system

4  Other strategies

Specify:

Health Coaching

The next set of questions are about health coaching only.

C5. Which of the following criteria does your organization consider when referring participants to Health Coaching?

Select all that apply

1  Participant risk level

2  Participant readiness to change

3  Accessibility of the resource (e.g., location, hours of operation)

4  We refer all women to Health Coaching GO TO C7

5  Priority goals identified

Specify:

C6. How does your program use readiness to change categories to determine participant eligibility for health coaching?

For the readiness to change categories listed below, indicate whether a participant in the specified category would be eligible for health coaching, would possibly be eligible for health coaching, or would not be eligible for health coaching?

	Select one response per row
	Eligible	Possibly eligible	Not eligible
a. Pre-contemplation	1 	2 	3 
b. Contemplation	1 	2 	3 
c. Preparation	1 	2 	3 
d. Action	1 	2 	3 
e. Maintenance	1 	2 	3 

C7. Does your program use any of the following methods to support completion of health coaching?

	Select one response per row
	Yes	No
a. Reminders by phone	1 	0 
b. Reminders by email	1 	0 
c. Provide incentives (such as coupons, prizes, and gifts)	1 	0 
d. Provide child care for participants	1 	0 
e. Provide transportation for participants	1 	0 
f. Our methods to facilitate completion of referrals to health coaching not listed above	1 	0 
Specify:

C8. How does your program track participation in health coaching?

Select all that apply

1  Information provided or submitted by health coaching providers

2  Follow-up with participants

3  Use of an integrated electronic tracking system

99  Other strategies

Specify:

Community Based Resources

The next question is about referrals to community based resources.

C9. During the current funding cycle, did your program refer participants to any of the following community-based resources?

Select all that apply

Physical Activity/Nutrition Resources

1  Recreation departments

2  Local parks

3  Walking/biking trails

4  Mall walking programs

5  Gardening programs

6  Food coupon programs

7  Farmers’ markets

8  Nutrition classes

Tobacco Cessation Resources

9  Quit line

10  Community-based tobacco cessation program

11  Translation services for quit lines

Other Resources

12  Mental health services

13  Job training

14  Translation services

15  Violence prevention services

16  Transportation services

17  Discount/free cost medication programs

18  Faith based programs

99  Other

Specify:

98  Program did not make any community-based resource referrals this funding cycle

C10. The next questions are about referrals to lifestyle programs, health coaching, AND other community-based resources.

In your program, which of the following types of staff make referrals to lifestyle programs, health coaching, and other community-based resources?

	Select one response per row
	Yes	No
a. Primary care doctor	1 	0 
b. Nurse	1 	0 
c. Nutritionist/ dietician	1 	0 
d. Health educator	1 	0 
e. Social workers/ case managers	1 	0 
f. Community health workers (Lay Health Workers/educators, community health advocates, community health outreach workers, Promotores y Promotoras de Salud)	1 	0 
g. Pharmacist	1 	0 
h. Other staff	1 	0 

C11. Which of the following are challenges participants of your program face when completing referrals to lifestyle programs, health coaching, and other community-based resources?

	Select one response per row
	Yes	No
a. Lack of time	1 	0 
b. Lack of access to culturally appropriate services	1 	0 
c. Lack of transportation	1 	0 
d. Lack of child care	1 	0 
e. Substance abuse	1 	0 
f. Depression or other mental health conditions	1 	0 
g. Domestic/ intimate partner violence	1 	0 
h. Language barriers	1 	0 
i. Inconvenient service hours	1 	0 
j. Lack of support from family and friends	1 	0 
k. Lack of interest in modifying health behaviors	1 	0 
l. Other barrier(s)	1 	0 
Specify:

SECTION D. MONITORING AND EVALUATION

The next section is about your program’s monitoring and evaluation efforts.

D1. How does your program use MDE data?

Select all that apply

1  Monitor outcomes of clinical services

2  Monitor outcomes of lifestyle programs and health coaching

3  Monitor outcomes of other community-based programs/ services

4  Evaluate and measure program performance

5  Conduct data quality assurance

6  Prepare reports

7  Communicate program efforts and results to the CDC, the public, legislators, and other stakeholders

99  Other use of MDE data

Specify:

D2. Since July 2013, on which of the following topics have your program’s evaluation activities focused?

Select all that apply

1  Baseline screenings

2  Efforts to address uncontrolled hypertension

3  Health care quality

4  Health risk assessments

5  Risk reduction counseling

6  Lifestyle programs

7  Health Coaching

8  Other community-based programs/ resources

9  Medication access

10  Partnerships

11  We evaluate other program activities

Specify:

1 2  We do not conduct any evaluations of our program GO TO E1

D3. Which of the following evaluation methodology does your program use?

An evaluation methodology defines the parameters and approach to answering research questions.

Select all that apply

1  Comparison group

2  Cross-sectional descriptive analysis

3  Longitudinal/time series design

4  Pre-post design

5  Trend analysis

99  Other method not listed above

Specify

D4. Since July 2013, which of the following has your program used to conduct evaluations?

	Select one response per row
	Yes	No
a. MDEs	1 	0 
b. Program administrative data	1 	0 
c. Case studies	1 	0 
d. Interviews or surveys with stakeholders (such as participants, program staff, and partners)	1 	0 
e. Other data sources	1 	0 
Specify:

D5. Since July 2013, in which of the following ways has your program shared evaluation findings with stakeholders and the public? Have you used…

If you do not share evaluation findings, please select “no” to all.

	Select one response per row
	Yes	No
a. Best practice toolkits	1 	0 
b. Fact sheets	1 	0 
c. Issue briefs	1 	0 
d. Reports	1 	0 
e. Journal articles	1 	0 
f. Webinars	1 	0 
g. Live presentations	1 	0 
h. Other way(s) not listed above	1 	0 
Specify:

D6. Since July 2013, has your program shared evaluation findings to any of the groups listed below?

If you do not share evaluation findings, please select “no” to all.

	Select one response per row
	Yes	No
a. Other grantees	1 	0 
b. Local policy makers	1 	0 
c. CDC	1 	0 
d. Other federal policy makers	1 	0 
e. Participants	1 	0 
f. Program staff	1 	0 
g. Partners	1 	0 
h. Other groups (specify)	1 	0 
Specify:

SECTION E. ADDITIONAL FEEDBACK

E1. Is there anything else you would like to share about your WISEWOMAN program?

Thank you for taking the time to complete the survey!

Please return the completed pdf to [email protected].