Additional County Supplement

Attachment E: CHPIA Additional County SUpplement

Form Approved

OMB No. 0920-0879

Expiration Date 03/31/2018

CHPIA Additional County Supplement

Use this form to provide responses about additional counties in a multi-county health district

Which county are you describing on this form? __________________________________

1. Overall, how much of an impact does your health department/district have on the process for making policies related to chronic disease prevention and health promotion for the residents who live in your county/district? Please select one.

O1 Large impact

O2 Moderate impact

O3 Small impact

O4 Very small impact

O5 No impact

O6 Don’t Know

2. In the past 12 months, how often did your health department/district partner with the following agencies or departments for the purpose of advancing policies related to chronic disease prevention and health promotion?
	1Always	2Often	3Sometimes	4Rarely	5Never	6Don’t Know
Zoning	O	O	O	O	O	O
Comprehensive land use planning	O	O	O	O	O	O
Transportation	O	O	O	O	O	O
Public works	O	O	O	O	O	O
Restaurant/hospitality inspection	O	O	O	O	O	O
Public safety/policing	O	O	O	O	O	O
Education/school system	O	O	O	O	O	O
Parks and recreation	O	O	O	O	O	O

CDC estimates the average public reporting burden for this collection of information as 8 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).

3. In the past 12 months, how often did your health department/district partner with the following entities or organizations for the purpose of advancing policies related to chronic disease prevention and health promotion?
	1Always	2Often	3Sometimes	4Rarely	5Never	6Don’t Know
State health department	O	O	O	O	O	O
Municipalities within the county/district	O	O	O	O	O	O
Municipalities in other counties/districts	O	O	O	O	O	O
Nonprofit organizations (Red Cross, American Heart Association, PTAs)	O	O	O	O	O	O
Public and private schools (K-12)	O	O	O	O	O	O
Colleges and universities	O	O	O	O	O	O
Hospitals, health systems, or other clinical providers	O	O	O	O	O	O
Pharmacies	O	O	O	O	O	O
Large employers in county/district	O	O	O	O	O	O
Fitness or wellness centers	O	O	O	O	O	O
Places of worship	O	O	O	O	O	O

4. Are there organizations that your health department/district has not been able to form a partnership with for the purpose of advancing policies related to chronic disease prevention and health promotion but would like to work with?

O1 Yes 4a. Please list: ___________________________________________________________________

O2 No

5. In the past 12 months, how often did your health department/district face the following barriers to partnering with other agencies?
	1Always	2Often	3Sometimes	4Rarely	5Never	6 NA-Never tried partnering
Bureaucratic organization barrier	O	O	O	O	O	O
Workload or time constraint	O	O	O	O	O	O
Other agencies or organizations not interested	O	O	O	O	O	O
Budget constraints	O	O	O	O	O	O
Not aware of other agencies to work with	O	O	O	O	O	O

6. In the past 12 months, how often did your health department/district use the following communication channels to increase awareness of policies related to chronic disease prevention and health promotion?
	1Always	2Often	3Sometimes	4Rarely	5Never	6 Don’t Know
Public service announcements	O	O	O	O	O	O
Facebook	O	O	O	O	O	O
Twitter	O	O	O	O	O	O
YouTube	O	O	O	O	O	O
Email contact lists	O	O	O	O	O	O
Mobile apps	O	O	O	O	O	O

Tobacco Policy

Using the categories below, please indicate the status of tobacco policy in your county/district.
Category	Response	Response Options
Smoke-free indoor air policies	_______	1 = This has not been identified as a policy priority in this county/district 2 = This has been identified as a policy priority and an agenda is being developed 3 = A policy is being formulated for adoption 4 = A policy has been adopted and is being implemented 5 = A policy is in place in some municipalities but not within the county/district as a whole 6 = A policy is implemented and is being enforced and evaluated 7 = Don’t Know
Policies on tobacco use in public or subsidized housing	_______
Smoke-free outdoor air policies	_______
Reducing minor access to tobacco products	_______
Limiting locations where tobacco is sold or point of sale restrictions	_______
Raising the cost of tobacco products by increasing taxes, restricting use of promotional coupons, or setting minimum price floors	_______
Regulating emerging tobacco products, such as hookahs or e-cigarettes	_______

7. If a new policy initiative related to tobacco use were to be proposed, how much of a role would your county health department/district have in the policy development process?

O1 O2 O3 O4 O5 O6

No Role Major Role Don’t Know

7. If a new policy initiative related to medical and/or recreational marijuana use were to be proposed, how much of a role would your county health department/district have in the policy development process?

O1 O2 O3 O4 O5 O6

No Role Major Role Don’t Know

Nutrition Policy

Using the categories below, please indicate the status of nutrition policy in your county/district.
Category	Response	Response Options
Policies related to sodium-reduction/control	_______	1 = This has not been identified as a policy priority in this county/district 2 = This has been identified as a policy priority and an agenda is being developed 3 = A policy is being formulated for adoption 4 = A policy has been adopted and is being implemented 5 = A policy is in place in some municipalities but not within the county/district as a whole 6 = A policy is implemented and is being enforced and evaluated 7 = Don’t Know
Policies or incentive programs that encourage the addition of new supermarkets, groceries or similar stores to the county/district	_______
Policies or incentive programs that improve the availability of healthy foods and beverages in existing food retail stores	_______
Nutrition standards or other policies related to foods served or sold in government facilities	_______
Nutrition standards or other policies related to foods served or sold in schools	_______
Nutrition standards or other policies related to foods served in child care settings	_______
Nutritional or menu labeling in restaurants or similar venues.	_______
Policies or incentive programs that encourage farmers markets, farm stands, and/or produce carts	_______
Policies that allow all breastfeeding employees in the local government time and space to pump breast milk.	_______

7. If a new policy initiative related to nutrition were to be proposed, how much of a role would your county health department/district have in the policy development process?

O1 O2 O3 O4 O5 O6

No Role Major Role Don’t Know

Physical Activity Policy

Using the categories below, please indicate the status of physical activity policy in your county/district.
Category				Response	Response Options
Policies that encourage pedestrian friendly streets and communities				_______	1 = This has not been identified as a policy priority in this county/district 2 = This has been identified as a policy priority and an agenda is being developed 3 = A policy is being formulated for adoption 4 = A policy has been adopted and is being implemented 5 = A policy is in place in some municipalities but not within the county/district as a whole 6 = A policy is implemented and is being enforced and evaluated 7 = Don’t Know
Policies that support accessible park and playground development near residential areas				_______
Policies related to public transportation				_______
Policies for physical education, recess or other opportunities for children to be physically active in schools				_______
Policies that encourage physical activity in child care centers				_______
Shared-use agreements with schools that allows the public to use school recreational facilities (for example, gymnasiums, athletic fields, or playgrounds) during non-school hours				_______
Safe route to school policies to encourage walking and bicycling to school				_______
Policies promoting sun safety and skin cancer prevention in schools (e.g., carrying and using sunscreen, hat wearing in outdoor settings)				_______

7. Is there a designated public health representative from your health department/district on the…

1. Planning and/or zoning commission?

O1 Yes

O2 No

O3 No such commission / committee

O4 Don’t Know

2. Pedestrian, bicycle, or alternative transportation advisory committee?

O1 Yes

O2 No

O3 No such commission / committee

O4 Don’t Know

7. If a new policy initiative related to physical activity were to be proposed, how much of a role would your county health department/district have in the policy development process?

O1 O2 O3 O4 O5 O6

No Role Major Role Don’t Know

Clinical-Community Linkages Policy

7. Using the categories below, please indicate the status of policy related to clinical-community linkages in your county/district.

Category	Response	Response Options
Policies promoting clinical and community linkages with pharmacies to control chronic diseases	_______	1 = This has not been identified as a policy priority in this county/district 2 = This has been identified as a policy priority and an agenda is being developed 3 = A policy is being formulated for adoption 4 = A policy has been adopted and is being implemented 5 = A policy is in place in some municipalities but not within the county/district as a whole 6 = A policy is implemented and is being enforced and evaluated 7 = Don’t Know
Policies promoting prevention and self-management of chronic disease	_______
Policies promoting immunizations (e.g., vaccines)	_______
Policies related to screening for chronic disease (e.g., blood pressure, blood glucose)	_______
Policies promoting clinical linkages with community health workers	_______
Policies related to emergency medical services (e.g., EMS training, public access defibrillation)	_______

7. If a new policy initiative related to chronic disease management were to be proposed, how much of a role would your county health department/ district have in advancing policy?

O1 O2 O3 O4 O5 O6

No Role Major Role Don’t Know

Policies for Reducing Excessive Alcohol Consumption

7. Using the categories below, please indicate the status of policy to reduce excessive alcohol consumption in your county/district.

Category	Response	Response Options
Increasing alcohol taxes	_______	1 = This has not been identified as a policy priority in this county/district 2 = This has been identified as a policy priority and an agenda is being developed 3 = A policy is being formulated for adoption 4 = A policy has been adopted and is being implemented 5 = A policy is in place in some municipalities but not within the county/district as a whole 6 = A policy is implemented and is being enforced and evaluated 7 = Don’t Know
Regulation of alcohol outlet density	_______
Commercial host (dram shop liability)	_______

7. If a new policy initiative related to reducing excessive alcohol consumption were to be proposed, how much of a role would your county health department/ district have in advancing policy?

O1 O2 O3 O4 O5 O6

No Role Major Role Don’t Know

CHECKPOINT: If you are part of a multicounty district, don’t forget to fill out the supplement questions about the other counties!

7. Your responses to this assessment are important for identifying the role of local health departments in setting policy. If you were to be asked to take this assessment again, how would you prefer to answer the questions?

O1 Over the phone

O2 By web

O3 On paper by mail

Thank you for your responses. Please return this assessment using the self-addressed stamped envelope included in your mailing. In the event you no longer have the envelope, please return to:

RTI International – ROC

Attn: Data Capture 0214510.004.001.001

5265 Capital Blvd.

Raleigh NC 27616

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