Form 0920-0879 Att C InstrumentMSWord

Attachment C – Instrument MS Word

Form Approved

OMB No. 0920-0879

Expiration Date 03/31/2018

Welcome to the Centers for Disease Control and Prevention’s (CDC) baseline profile assessment for state and local healthy homes and lead poisoning prevention programs.

You have been asked to take part in a profile assessment as a state or local public official operating in your official capacity as decision-maker within a lead and healthy homes program.

The purpose of the assessment is to identify 1) jurisdictional legal frameworks governing CDC-funded childhood lead poisoning prevention programs in the United States, and 2) strategies for implementing childhood lead poisoning prevention activities in the United States.

The information collection will allow the CDC Healthy Homes and Lead Poisoning Prevention Program to identify common characteristics of awarded childhood lead poisoning prevention programs. The dissemination of results of this information collection will ensure that non-funded jurisdictions are able to develop and apply similar strategies to support the national agenda to eliminate childhood lead poisoning. The information collection will also inform guidance, resource development and technical assistance activities the CDC Healthy Homes and Lead Poisoning Prevention conducts in support of the ultimate elimination goal. Assessment findings will be shared in response to inquiries by the public, press, and Congress.

The data will be kept secure throughout the analysis and reporting process.

This assessment should take no more than 7 minutes to complete. You may stop taking the assessment and finish it at a later time.  However, you must continue taking the assessment on the same computer or mobile device on which you started taking the assessment. Please do not take this assessment on a mobile device while you are driving.

Please complete the assessment by [INSERT DATE]. 

It is your choice to complete the assessment.  You may choose not to answer any question for any reason.  You can stop taking the assessment at any time.  No individually identifiable information will be requested.

If you have programmatic questions, you can contact CDC Healthy Homes and Lead Poisoning Prevention Program Health Scientist, Elise Lockamy, at [email protected] or 770-488-0050.

1. Please choose one option below to continue:

□ I agree to participate in the assessment.

□ I do not want to participate in the assessment. (THANKS AND EXIT ASSESSMENT)

CDC estimates the average public reporting burden for this collection of information as 7 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0879).

Section 1

2. Program Title (ex. New State Childhood Lead Poisoning Prevention Program)

2. City of Program Headquarters

2. State of Program Headquarters

2. Does your jurisdiction have legislation mandating the existence or operation of a childhood lead poisoning prevention program?

□ Yes

□ No

□ Other (please specify)

2. Does your jurisdiction have an electronic reporting law for laboratories?

□ Yes

□ No

□ Other (please specify)

2. Does your jurisdiction have a lead paint abatement law?

□ Yes

□ No

□ Other (please specify)

(ANY ANSWER, CONTINUE TO SECTION 2)

Section 2

2. Current screening strategy: (select all that apply)

□ Targeted

□ Universal

2. Estimated number of children –

Under six years of age in your service area

Under six years of age who are members of high-risk populations

Under six years of age who are living in high-risk geographic locations

2. What confirmed venous blood lead level prompts the following intervention –

Letter / Brochure to the family

Phone Call to the family

Home Visit for Risk Assessment

Full Lead Inspection

Full Healthy Homes Inspection

2. Does your Program receive Medicaid reimbursement for healthy homes and lead poisoning prevention related services?

□ Yes

□ No

□ Other (please specify)

(ANSWER “Yes” OR “Other”, CONTINUE TO QUESTION 12; ANSWER “No”, END ASSESSMENT)

2. If your Program receives Medicaid reimbursement, list the reimbursable services and accompanying reimbursement rate. (Insert N/A if your Program does not receive Medicaid reimbursement.)

(THANKS AND EXIT ASSESSMENT)