Systematic Identification and Assessment of Sexual Violence Prevention Strategies

Attachment E—Instrument Word Version

Form Approved

OMB No. 0920-0879

Expiration Date 03/31/2018

[Page 1: Welcome]

Sexual Violence Prevention Strategy Description

Thank you for taking the time to nominate a sexual violence (SV) prevention strategy! This information collection is meant for program managers of health departments in 50 states, the District of Columbia, and four U.S. territories (awardees) and their delegates (sub-awardees) acting on behalf of those health departments in their official capacities funded through CDC’s Rape Prevention and Education (RPE) Program cooperative agreement (CDC-RFA-CE14-1401).

The purpose of this collection is to obtain information about SV prevention strategies developed in practice (practice-based) that are ready for more assessment. We are especially interested in practice-based SV prevention strategies that promote protective factors and reduce risk factors at the community and societal levels of the Social Ecological Model. We are specifically looking for prevention strategies that focus on any of the following: (1) creating safe and protective environments, (2) promoting healthy social norms that protect against SV, (3) using gender equity approaches.

To nominate an SV prevention strategy, please complete the form which asks you to describe strategy goals and focus, strategy implementation, and information collection and assessment efforts. CDC may contact program staff to obtain more information, if necessary.

Your submission is important to us and will help us to identify practice-based prevention strategies that have high potential for widespread adoption, high potential for population-level impact on sexual violence outcomes, and are ready for more assessment.

Completing the Sexual Violence Prevention Strategy Description is voluntary and takes approximately 40 minutes. Your responses will be secure to safeguard against any breach of personally identifiable information. No sensitive information will be collected. You must complete the Sexual Violence Prevention Strategy Description in one sitting, as answers to questions cannot be saved.

Submission Deadline: [DATE]

If you have questions about whether strategies may be a good fit to be nominated, please send an email to [email protected] with “SSA” starting the subject line.

To begin, please click “Next”. You can edit previous responses as you complete the nomination. To return to a previous page, use the “Previous” button at the bottom of the page (NOT the “Back” button on your browser menu). To advance, use the “Next” button at the bottom of the page.

Public reporting burden of this collection of information is estimated to take no more than 40 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing 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 information collection, including suggestions for reducing this burden to CDC/Agency for Toxic Substance and Disease Registry Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attention: PRA (0920-0879).

*Denotes required questions

[Page 2: Contact Information]

Contact Information

To return to a previous page, use the “Previous” button at the bottom of the page (NOT the “Back” button on your browser menu). To advance, use the “Next” button at the bottom of the page.

1. Prevention strategy name:* [Open field comment box]

2. State or territorial agency/organization where the prevention strategy is being implemented* [Dropdown]

• Alabama

• Alaska

• Arizona

• Arkansas

• California

• Colorado

• Commonwealth of Northern Mariana Islands

• Connecticut

• Delaware

• District of Columbia

• Florida

• Georgia

• Guam

• Hawaii

• Idaho

• Illinois

• Indiana

• Iowa

• Kansas

• Kentucky

• Louisiana

• Maine

• Maryland

• Massachusetts

• Michigan

• Minnesota

• Mississippi

• Missouri

• Montana

• Nebraska

• Nevada

• New Hampshire

• New Jersey

• New Mexico

• New York

• North Carolina

• North Dakota

• Ohio

• Oklahoma

• Oregon

• Pennsylvania

• Puerto Rico

• Rhode Island

• South Carolina

• South Dakota

• Tennessee

• Texas

• U.S. Virgin Islands

• Utah

• Vermont

• Virginia

• Washington

• West Virginia

• Wisconsin

• Wyoming

3. City and/or county where the prevention strategy is being implemented

   • City (if implemented in more than one city, please list all): [Open field comment box]

   • County (if implemented I more than one county, please list all): [Open field comment box]

4. Please provide the contact information for whom we could contact for more information about the prevention strategy.*

   • Agency: [Open field comment box]

   • First Name: [Open field comment box]

   • Last Name: [Open field comment box]

   • Agency Address: [Open field comment box]

   • Agency Phone: [Open field comment box]

   • Agency Email: [Open field comment box]

   • Website (if applicable): [Open field comment box]

5. Please provide contact Information for the person nominating this prevention strategy.*

☐ Same contact information as primary contact.

☐ Different contact information. Please provide first name, last name, phone number and email.

_______[Contact information]_____________________

6. Is the agency/organization nominating the prevention strategy funded by CDC’s Rape Prevention and Education (RPE) Program cooperative agreement (CDC-RFA-CE14-1401)?*

☐ No [If no, continue to Page 3: Q7]

☐ Yes [If yes, skip to Page 5: Q8]

[Page 3: Contact Information]

To return to a previous page, use the “Previous” button at the bottom of the page (NOT the “Back” button on your browser menu). To advance, use the “Next” button at the bottom of the page.

7. Is the agency/organization nominating the prevention strategy a sub-contract/award for the state RPE Program?*

☐ No [If no, continue to Page 4]

☐ Yes [If yes, skip to Page 5: Q8]

[Page 4: Contact Information]

At this time, we are only able to accept nominations submitted by RPE awardees and sub-awardees.

If your agency/organization is an RPE awardee or sub-awardee and you'd like to continue nominating a prevention strategy, please click on the “previous” button on the bottom of the page to return to the nomination form. [If “previous”, will return to Page 3: Q7]

If your agency/organization is not an RPE awardee or sub-awardee, please click "next" to exit the form. [If “next”, will skip to Disqualification Page]

[Page 5: Strategy Goals and Focus]

Strategy Goals and Focus

The following questions are about focus, goals, main activities, and outcomes of the prevention strategy.

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8. Which focus area(s) best describe(s) the sexual violence prevention strategy being nominated? (Please check all that apply).*

☐ Creating safe and protective environments

☐ Modify characteristics of the community (e.g., schools, neighborhoods, workplace, or institutions) rather than individuals within the community

☐ Change to institutional structures or the social and physical environment in an effort to reduce risk factors or conditions and increase protective factors that affect the entire community (e.g., improved economic security for women and girls)

☐ Promoting healthy social norms that protect against sexual violence

☐ Change social norms that allow indifference to, accept, or condone violence, for example, reducing restrictive gender norms (i.e., rigid ideas about the appropriate roles and behavior of men and women)

☐ Provide peer leadership around preventing sexual violence and motivating individuals to promote protective norms, to help when they see behavior that puts others at risk of violence, and to take appropriate steps to safely and effectively intervene

☐ Using gender equity approaches

☐ Mobilize men and boys as allies or empower girls through strengthened leadership and opportunities

☐ Address factors related to gender equity such as balance of power, equal pay, or positive norms about masculinity, gender, and violence among individuals

☐ Other [Open field comment box]

9. Which level(s) of the Social Ecological Model does the prevention strategy address? (Please check all that apply).*

☐ Individual (e.g., attitudes, beliefs, skills, and behaviors)

☐ Relationship (e.g., social circle peers, partners, family members)

☐ Community (e.g., schools, workplaces, neighborhoods)

☐ Societal (e.g., social and cultural norms)

[Page 6: Strategy Goals and Focus]

Please describe the strategy in enough detail to explain the main components, activities, target population, and setting.

To return to a previous page, use the “Previous” button at the bottom of the page (NOT the “Back” button on your browser menu). To advance, use the “Next” button at the bottom of the page.

10. What are the main components and activities of the prevention strategy?* [Open field comment box]

11. Has the strategy been adapted from an existing promising or evidence-based strategy?*

(Adaptations include additions, deletions, and modifications to content and/or delivery methods including changes to sequence. For example: Have you borrowed materials from a promising or evidence-based strategy? Have you adapted a promising or evidence-based strategy by changing the target population?)

• No [If no, skip to Page 8: Q13]

• Yes (If yes, please provide name of the promising or evidence-based strategy) [If yes, continue to Page 7: Q12] ___[Name of promising or evidence-based strategy]___

[Page 7: Strategy Goals and Focus]

To return to a previous page, use the “Previous” button at the bottom of the page (NOT the “Back” button on your browser menu). To advance, use the “Next” button at the bottom of the page.

12. Please explain in a few sentences or less how the strategy was adapted or changed. (Adaptations include additions, deletions, and modifications to content and/or delivery methods including changes to sequence. For example: Have you borrowed materials from a promising or evidence-based strategy? Have you adapted a promising or evidence-based strategy by changing the target population?)* [Open field comment box]

[Page 8: Strategy Goals and Focus]

To return to a previous page, use the “Previous” button at the bottom of the page (NOT the “Back” button on your browser menu). To advance, use the “Next” button at the bottom of the page.

13. Who is affected by the prevention strategy (i.e. target population)? Please briefly describe the characteristics of the target population of the prevention strategy being implemented.* [Open field comment box]

14. What outcome(s) do(es) the strategy address? What changes do you expect to see? What changes have you seen?* [Open field comment box]

[Page 9: Strategy Implementation]

Strategy Implementation

The following questions ask you to elaborate on how the prevention strategy is being implemented. Please use the comment boxes provided to describe the strategy’s duration of implementation and resources necessary for implementation.

To return to a previous page, use the “Previous” button at the bottom of the page (NOT the “Back” button on your browser menu). To advance, use the “Next” button at the bottom of the page.

15. In what setting(s) is the prevention strategy being implemented? (e.g., school, workplace, bars)* [Open field comment box]

16. How long has the strategy been implemented? (Note: If the strategy has been implemented in multiple settings for various durations, please indicate that here.)* [Open field comment box]

17. Describe the current reach of the prevention strategy. How much of the target population have you been able to reach?* [Open field comment box]

18. What resources (e.g., funding, staff, support) are necessary to implement this prevention strategy?* [Open field comment box]

[Page 10: Information Collection and Assessment Efforts]

Information Collection and Assessment Efforts

The following questions ask you to describe any current assessment efforts and capacity for future data collection. Please use the comment boxes provided to write your responses.

To return to a previous page, use the “Previous” button at the bottom of the page (NOT the “Back” button on your browser menu). To advance, use the “Next” button at the bottom of the page.

19. What (if any) information or data are being collected about the implementation of the strategy? How are the information or data collected and/or tracked? Please write “none” if you are not currently collecting information or data about the implementation of the strategy.* [Open field comment box]

20. What (if any) information or data are being collected about the outcome(s) of the strategy? How are the information or data collected and/or tracked? Please write “none” if you are not currently collecting information or data about the outcome(s) of the strategy.* [Open field comment box]

21. What other information or data could potentially be collected?* [Open field comment box]

[Page 11: Additional Questions]

Additional Questions

Please share any additional information with us about why you are nominating this prevention strategy.

When finished, please click “Done” to submit the nomination form. You can edit previous responses as you complete the form. To return to a previous page, use the “Previous” button at the bottom of the page (NOT the “Back” button on your browser menu).

22. Why are you nominating this prevention strategy?* [Open field comment box]

23. Is there any additional information you’d like to share about the prevention strategy? [Open field comment box]

[Confirmation Page]

Thank you for your submission!

CDC staff will be in contact with you with any follow-up questions we may have. If you have any questions or for more information, please visit [CDC web link] or contact dvpevaluation@cdc.gov.

[Disqualification Page] (Skip pattern from Page 4)

At this time, we are only able to accept nominations submitted by RPE awardees and sub-awardees. Thank you for your interest! If you have any questions please contact dvpevaluation@cdc.gov or visit [CDC web link].