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2014 CRCCP Survey

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Form Approved
OMB No. 0920-XXXX
Expiration Date: XX/XX/20XX

CDC Colorectal Cancer Control Program (CRCCP)
Grantee Survey of Program Implementation
Public reporting burden of this collection of information is estimated to average 75 minutes per response including the time for reviewing the instructions 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/ATSDR Information
Collection Review Office, 1600 Clifton Road, NE, MS D-74, Atlanta, GA 30333. ATTN: PRA(0920-XXXX)

SURVEY PURPOSE

Thank you for taking the time to complete the 2014 CRCCP Grantee Survey of Program Implementation! This survey is very similar to the one you
completed last fall; it will take time, thought, and in some cases investigation on your part to answer the questions thoroughly. The information
you provide will help us understand how grantees are implementing the CRCCP, including the evidence-based interventions recommended by the
Guide to Community Preventive Services (Community Guide). Results of the survey will be incorporated into a year five CRCCP grantee report for
you and other stakeholders.
The purpose of this survey is to:
1. Understand how grantees are implementing CDC’s Colorectal Cancer Control Program (CRCCP)
2. Assess how implementation changes each year
3. Collect information related to technical assistance and training needs
INSTRUCTIONS AND SURVEY INFORMATION
Updated 9/21/14

Who should complete the survey?
The person responsible for day-to-day management of the program should complete this survey. He or she is encouraged to consult with others
as needed to answer the questions as completely as possible.
For what time period am I reporting?
Please answer all questions for the program year 5 (PY5), time period: July 1, 2013 – June 30, 2014.
How is this survey different from last year’s survey?
This year’s survey is similar to the annual Grantee surveys you've been completing since 2011. The majority of the content is the same. The
biggest changes to the 2014 survey are:
Re-inserted questions: Last year we deleted items throughout the survey that were unlikely to change since 2012. We have reinserted these
questions. We have also added some questions to help us continue to understand how your CRCCP may be affected by Affordable Care Act (ACA)
legislation.
What topics are covered in the survey?
The survey covers the same content as in the previous survey years. It is organized into the following sections:
Background: Respondent Information
Section 1: [Re-inserted] CRCCP Management and Integration with Other Programs
Section 2: CRC Screening Provision
Section 3: CRC Screening Promotion
Section 4: CRC Screening Data from FQHCs and IHS Clinics
Section 5: Training and Technical Assistance for Evidence-Based Interventions
Section 6: Screening Policies and Strategies
Section 7: General Program Management (i.e., Monitoring and Evaluation, Administrative Issues)

However, some questions may not pertain to your organization and in such cases you may skip those sections.
Given the length of the survey, you may wish to complete the survey in several sittings. The following groupings may be “natural” chunks:
Background + Sections 1 and 2
Sections 3 and 4
Sections 5, 6, and 7

If you leave the survey or close your Internet browser, the next time you visit the survey link, you will be directed to the same page from which
you left.
Are you including contractors and partner organizations when you refer to “my CRCCP”?
For purposes of simplicity, the survey will refer to all grantees’ programs as the CRCCP, even though most grantees have given their programs a
unique name. Questions will also refer to your CRCCP as “your organization.” In all instances, "your organization" is meant to include the
organization that is the main cooperative agreement recipient, as well as any of your contractors. We understand that you may also be working
with unfunded partner organizations to implement your CRCCP. The survey includes questions that will ask about partners, whether funded or

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unfunded.
Sections 2 and 3: My state’s CRCCP program is funded by both state and federal funds. All of our contractors use state funds to
fund their colorectal cancer screening, but only some use federal funds. When speaking of screening (promotion or provision), do
you only want us to talk only about screenings funded through the CRCCP?
For the screening provision/promotion sections of the survey, please include only the contractors that are paid by CRCCP (federal) funds.
However, to help us get a more complete picture of your state’s screening efforts, at the end of the appropriate provision or promotion section(s),
you'll be asked to tell us "anything else" about your CRC provision/promotion efforts; please use these boxes to tell us about your state’s CRCCP
overall screening services that are funded by both state/fed funds together, e.g. funding source proportion, anything about your other
contractors, their combined and/or separate reach, etc. If only some contractors receive federal CRCCP funds, please also provide information in
the comments areas regarding why those contractors were chosen by your CRCCP, and based on what selection criteria they were chosen, (e.g.
was having contractors deal with CDC data collection of CDEs an issue?)
Can I receive a summary of my survey results for our files?
Yes! Instructions for receiving a copy of your responses will appear at the end of the survey.
Who can I contact with questions about the survey?
Please contact Thuy Vu at [email protected] or 206-669-0897
Who can I contact about technical difficulties with the web survey?
Please contact Thuy Vu at [email protected] or 206-669-0897
Can I download and print out a hard copy of the survey?
Yes! You may find it helpful to download the survey and skim through it first. This will add some time up-front, but it will give you an idea not just
of the questions being asked, but of where you might need to consult with your colleagues to answer the questions as accurately as possible.
If you identify questions where you’ll need to consult with your colleagues, copy and paste the question(s) from the print document (PDF) into a
new document or email, or print the document and flag the item(s) or page(s) to show your colleague; unfortunately you cannot email specific
questions directly from the web survey.
The printed version of the survey will look long, but keep in mind that it includes every question, even the ones that you will not need to answer.
(In the web survey, as you answer each question, you will be shown only the next question that you need to answer. As a result, question
numbering in the online survey may not seem sequential, as some questions will be skipped.)
To download and print the survey:
Click here to download a PDF of the survey.
Right click on the link above and choose “Save link as” to save the PDF to a specific location on your computer.
Open the PDF by double clicking it and click the print button. (If you do not have Adobe Reader, you will have to install Adobe Reader. Click here
to get the free Adobe Reader software.
What are examples of types of questions where I’ll need to consult with colleagues or partners to answer them?
Examples of questions that may require consultation with your colleagues or partners are included in the FAQ. You can download the FAQ here, or
by clicking on the FAQ link at any time at the top of the survey screen.
Can I save my survey progress and continue it at a later time?
Yes! If you leave the survey or close your Internet browser, the next time you visit the survey link, you will be directed to the same page from
which you left.
Can I go back and review or change my answers?
Yes. Use the "Previous" button at the bottom of each screen to go back and review or update your response.
Please note that at the end of the survey you will be able to review a summary of all the answers you provided.
RESPONDENT INFORMATION
1. With which grantee state or tribal organization are you affiliated?



-- Select One --

2. What is your name?
(for follow-up purposes only; names will not be used in reports)

3. What is your contact information?
(for follow-up purposes only, if necessary)
a. Phone number:
Example: XXX-XXX-XXXX
b. Email:
When you complete and submit your survey, an email confirmation will automatically be sent to the address you provide below.

c. Confirm email:

4. What is your position with the CRCCP?
(Check all that apply.)
Program director (the primary contact for the CRCCP Cooperative Agreement)
Program manager/coordinator (the day-to-day manager for the CRCCP)
Other (specify)
5. How long have you been working with the CRCCP in your state/tribal organization?
Less than 6 months
6 -11 months

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12-23 months
24-35 months
3 or more years
6. How long have you been working on cancer-related issues in your state/tribal organization or in other states/tribal/non-governmental
organizations?
Less than 1 year
1 to 3 years
4 to 5 years
6 to 9 years
10 or more years
7. Has there been a change in either your CRCCP’s Program Director (PD) or Program Manager (PM) during the duration of its funding period
(through July 2014)? Check all that apply
Yes, the PM changed
Yes, the PD changed
No, there has been no change in either the PD or PM furing out funding period

SECTION 1: CRCCP MANAGEMENT AND INTEGRATION
These first questions will give us a better idea of how your CRCCP was managed in PY5, and whether CRCCP staff were integrated with other CDCfunded programs or chronic disease programs. Specifically, we ask about the integration of your CRCCP program director, CRCCP program
manager/coordinator, and any other CRCCP staff, regardless of the funding source used to support them.

A. CRCCP Management & Integration With Other CDC-Funded Programs
1. Did the CRCCP program director (i.e., the person who is the primary program contact for the cooperative agreement), have work
responsibilities for any of the following CDC-funded programs in your state/tribal organization (regardless of the funding source used to
support him/her)?
(Check all that apply.)
WISEWOMAN
Comprehensive Cancer Control Program (CCC)
Breast and Cervical Cancer Early Detection Program (BCCEDP)
Central Cancer Registry
Other (please specify)
None
2. Was the program manager/coordinator and program director in your CRCCP, the same person, or are these two positions filled by different
people?
The CRCCP program manager/coordinator and CRCCP program director are the same person.
The CRCCP program manager/coordinator and CRCCP program director are different people.
2a. Did the CRCCP program manager/coordinator, (i.e., the person who is the day-to-day manager), have work responsibilities for any of the
following CDC-funded programs in your state/tribal organization (regardless of the funding source used to support them?
(Check all that apply.)
WISEWOMAN
CCC Program
BCCEDP
Central Cancer Registry
Other (please specify)
None
3. Were any CRCCP staff* integrated with, or have work responsibilities for, any of the following CDC-funded programs in your state/tribal
organization, (regardless of the funding source used to support him/her)?
*Note: For this question, CRCCP staff should not include the CRCCP program director or program manager/coordinator.
WISEWOMAN
CCC Program
BCCEDP
Central Cancer Registry
Other CDC-Funded Program
Yes
No
4. Not including either the CRCCP program director, or program manager/coordinator, complete the following sentence to tell us:
1) How many CRCCP staff were also integrated with, or have work responsibilities for, any of the CDC-funded programs (listed below) in your
state/tribal organization, and
2) Across how many other programs these CRCCP staff members were integrated.
CDC-funded programs:
WISEWOMAN
CCC Program
BCCEDP
Central Cancer Registry
Other CDC-Funded Program
-- Select One --- Select One --

 CRCCP staff is/are integrated across
 other CDC-funded Programs.

5. In the table below, tell us how often your CRCCP staff* performed, or had work responsibilities related to, the activities listed for other CDC-funded

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programs. If there is no "other" program or activity you must still enter "NA" or "none."
*Do not include your program director or program manager/coordinator
**Select "NA" from the drop-down list if your staff is not integrated with the program listed.
***Select "Never" from the drop-down list if your staff is integrated with the program listed, but they never perform the activity specified.
Other Program, (please
specify)

Central Cancer
Registry

WISEWOMAN

CCC Program

a. Public education, outreach, or
recruitment

-- Select One -- 

-- Select One -- 

-- Select One --



-- Select One --



-- Select One --



b. Quality assurance, quality
improvement, clinical support

-- Select One --



-- Select One --



-- Select One --



-- Select One --



-- Select One --



c. Data management

-- Select One --



-- Select One --



-- Select One --



-- Select One --



-- Select One --



d. Patient navigation

-- Select One -- 

-- Select One -- 

-- Select One --



e. Other
activity,
(please
specify)

-- Select One --



-- Select One --





BCCEDP

-- Select One -- 

-- Select One --



-- Select One -- 

-- Select One --



-- Select One --

6. Did your organization coordinate any training or professional development with any of the following CDC-funded programs?
(Check all that apply.)
WISEWOMAN
CCC Program
BCCEDP
Central Cancer Registry
Other CDC-Funded Program (please specify)
7. Overall, how easy or difficult has it been to integrate your CRCCP with other CDC-funded programs, such as WISEWOMAN, CCC Program,
BCCEDP, etc.?

Very easy

Somewhat
easy

Neutral

Somewhat
difficult

Very difficult

7.a. Describe the difficulties or barriers your organization experienced in trying to integrate with other CDC-funded programs.



7.b. Describe what made your CRCCP very easy to integrate with other CDC-funded programs.



B. Coordination with Other Chronic Disease Programs
1. Did your organization coordinate the delivery of any of your CRCCP activities (e.g. public education) with other chronic disease programs
(not including cancer programs or WISEWOMAN)?
Yes
No
1.a. With which chronic disease program(s) did your organization coordinate, for the delivery of any of your CRCCP activities?
(Check all that apply.)
Diabetes
Cardiovascular health
Community health
Immunization/Family health
Infectious disease
Other, please specify
2. Did your organization coordinate any staff training or professional development with other chronic disease programs?
Yes
No
2.a. With which chronic disease program(s) did your organization coordinate staff training or professional development?
(Check all that apply.)
Diabetes
Cardiovascular health
Community health
Immunization/Family health
Infectious disease

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Other, please specify
3. Did your organization coordinate any other internal activities or services (e.g. data management, planning, communications) with other
chronic disease programs?
Yes
No
3.a. With which chronic disease program(s) did your organization coordinate other internal activities?
(Check all that apply.)
Diabetes
Cardiovascular health
Community health
Immunization/Family health
Infectious disease
Other, please specify
SECTION 2: CRC SCREENING PROVISION
The screening provision component of the CRCCP includes activities that your organization implements to provide or support direct CRC screening
of low income, uninsured, and underinsured patients using CDC funds. These activities may include:
Providing screening and diagnostic services directly
Identifying and contracting with physicians or clinics to deliver screening services
Providing or promoting professional development/provider education
Promoting quality assurance (QA)/quality improvement (QI) standards among funded provider sites
Identifying and recruiting patients for CRCCP screening
Implementing or supporting the use of patient navigation/case management services for screening provision
Facilitating access to treatment for cancers diagnosed through your CRCCP
This section of the survey includes questions that ask about each of those activities for program year 5 (PY5; July 1, 2013 - June 30, 2014).
Questions about monitoring and evaluation, including collection of Colorectal Clinical Data Elements (CCDE) are asked later in this survey.

A. Screening test type and provider sites/clinics
1.a. What screening tests were used by your CRCCP in PY5?
(Check all that apply.)
Colonoscopy
FOBT
FIT
Sigmoidoscopy
1. What was the primary screening test used in PY5?
(Select one.)
"Primary" refers to the test that your organization supports/reimburses for the majority of providers/clinics .
Colonoscopy
FOBT -> Please specify brand(s) if known; if unknown enter, "Don’t Know"
FIT -> Please specify brand(s) if known; if unknown enter, "Don’t Know"
Sigmoidoscopy
2. Did the primary screening test change during PY5?
Yes
No
2.a. Please explain why your primary screening test changed and, if relevant, indicate whether the change was patient-, provider-, or policydriven (or other).



3. How many CRCCP sites or clinics participate in the screening provision component? In the questions below, enter the number of participating
sites or clinics according to the type of provider setting, e.g. primary care provider sites or clinics, endoscopy/GI sites, etc.
We understand that some CRCCPs may have a single contract with an organization that includes numerous sites or clinics and that not all of an
organization’s sites or clinics may participate in the CRCCP. Please provide the total number of CRCCP-participating sites or clinics that actually
deliver CDC-funded screening services.
For each type of provider
setting, enter the number
of participating sites or
clinics that deliver
screening services

NA – This clinic type
does not participate
in our

Type of Provider Setting
a. Individual or groups of primary care provider (PCP) sites or clinics, not
including FQHCs

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b. Endoscopy/Gastrointestinal (GI) sites or clinics
c. Federally Qualified Health Center (FQHCs)
d. Other, please specify
If you do not have an "other" you must select the "NA" option.
4. What is the geographic location of each CRCCP-participating clinic type that delivers CDC-funded screening services? For every row item,
check all that apply. If you do not have an “other” then you must still check, “NA.”

Regional

State/Tribewide

Multicounty/
tribe

Single
county/
tribe

City/local

Communityspecific e.g.
neighborhood

NA - This
clinic type
does not
participate
in our

a. Individual PCPs, not including
FQHCs
b. Endoscopy/GI
c. FQHCs
d.
Other,
please
specify
5. Since you began your screening efforts, has your CRCCP (including contractors) experienced any challenges in regards to capacity to
delivery screening services for the underinsured or uninsured (e.g., not enough endoscopists to provide colonoscopies/sigmoidoscopies, not
enough endoscopists in some parts of your state/tribe)? Please describe.



6. If your program uses FOBT and/or FIT tests for screening provision, do you implement specific activities to encourage patients to return
those kits?
Yes
No
Depends On Individual Providers
N/A - We do not use FOBT/FIT tests
6.a. What activities does your program consistently implement to encourage patients to return FOBT/FIT kits?



7. If your program has used FOBT and/or FIT tests for screening provision, do you implement specific activities to encourage annual
rescreening?
Yes
No
N/A. My organization has used FOBT/FIT for screening provision for less than one year
7.a. What activities does your program implement to encourage annual FOBT/FIT rescreening?



8. What population subgroups are prioritized for CRC screening provision by your program?
(Check all that apply.)
Black or African-American
White
Asian
American Indian or Alaskan Native
Native Hawaiian or other Pacific Islander
Hispanic, Latino or Spanish origin
Persons in specific geographic areas
Rarely or never screened populations
Rural populations
Urban populations
Immigrant/refugee populations
LGBTQ
Other

(please specify)

N/A - We do not prioritize any population subgroups for screening

B. Support Services and Patient Navigation for Screening Provision

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The following questions relate only to patient navigators/case managers serving patients screened with CDC funds, i.e., used as part of the
screening provision component of your CRCCP. Questions about patient navigators/case managers used for screening promotion will be asked
in a different section of the survey.
1. Were patient navigators or case managers used for the screening provision CRCCP?
Yes
No

2. How many patient navigators/case managers were supported as part of the CRCCP for screening provision?
We are interested in knowing more about the patient navigators/case managers that were supported as part of the CRCCP screening provision
component. In the table below, please provide the numbers to complete the following sentence, to tell us how many patient navigators/case
managers are supported as part of the CRCCP for screening provision.
____________ patient navigators/case managers, or ____________ FTEs (regardless of the number of people) were supported at
____________ CRCCP-participating sites or clinics in PY5 participating in my organization’s CRC screening provision efforts.
If your organization supported only per-patient navigation reimbursement or per-case management reimbursement, write-in "Don't
Know" (case sensitive) in each applicable field.
Patient Navigators/Case Managers
FTEs (regardless of the number of people)
At

Sites/Clinics

3. Please specify any core navigation activities that were routinely offered as part of your organization’s CRC screening provision
component. Check all that apply.
Patient assessment of barriers to screening
Patient education (about anatomy, CRC, CRC screening, bowel prep)
Assistance with transportation, language translation, child/eldercare
Assistance with appointment setting
Assistance with identifying payment for screening
Reminder calls/emails for bowel prep and/or appointments
Reminder calls/emails for return of FOBT/FIT tests
Peer support/motivation for screening
Follow-up with client about next steps for CRC screening and ensure understanding of results provided by medical team
Community outreach to promote CRCCP and colorectal screening. (E.g. linkages with health fairs and clients in the community)
Clinic in-reach activities to promote CRCCP and colorectal screening. (E.g. flagging charts for medical providers for those eligible for
Program/CRC screening)
4. Where were navigators/case managers who support patients screened by your organization housed?
(Check all that apply.)
Within the health department (state department of public health, tribal agency)
Regional or local agency(ies) (e.g., health department, contractor)
Screening provider site(s)
Partnering community agency(ies)
Other (specify)
5. Among the patient navigator/case managers supported by your organization for CRC screening provision, what is the highest level of
education they typically have?
(Check one.)
Less than high school
High school diploma or GED equivalent
Associate degree
Nursing degree
College degree
Graduate degree
Other, please specify
Don’t know
6. Among the patient navigator/case managers supported by your organization for CRC screening provision, what type of background or
experience do they typically have?
(Check all that apply.)
Knowledge of the priority population/community
Nursing
Social work
Health systems
Public health
Cancer survivor
Community lay health/ natural helper
Other, please specify
Don't know
7. What types of navigation activities were supported by your organization through the use of patient navigator/case managers for CRC
screening provision?
(Check all that apply.)
Patient recruitment for screening

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Patient assessment of patient barriers to screening
Patient education about CRC screening and testing modalities, including bowel prep for endoscopy
Making CRC screening reminder calls for bowel prep
Making CRC screening reminder calls for colonoscopy
Making CRC screening reminder calls to return FOBT/FIT kits
Assisting patients to access bowel prep materials
Scheduling CRC screening appointments
Arranging transportation to/from CRC screening appointments
Peer support for cultural or emotional concerns about CRC screening
Arranging dependent care so patients can go to CRC screening appointments
Meeting patients at endoscopic appointment
Arranging or providing translation services for CRC screening appointments
Making follow-up calls after colonoscopy
Assisting patients diagnosed with cancer get into cancer treatment
Tracking patients to be sure they complete their colonoscopy
Tracking patients to be sure they return their FOBT/FIT kits
Other, please specify
I do not know what activities are provided
8. Did your organization offer any screening provision support services that are not otherwise provided through a patient navigation or case
management system?
Yes
No
8a. Please describe the screening provision support services that are not otherwise provided through a patient navigation or case
management system.



9. How were the patient navigators/case managers for CRC screening provision supported? (Check all that apply.)
Reimbursement to providers for FTE support
Per- patient navigation/case management reimbursement
Grantee staff serving as patient navigators/case managers
In-kind navigators/case managers from a community partner/program
Other (specify)
10. During PY5, did any of your patient navigators/case managers collect and report non-clinical screening data about navigation services
delivered (e.g., number of clients receiving navigation/case management, number of clients assessed for barriers, number and types of
patient navigation contacts per client, percentage of clients navigated that completed screening).
Yes
No

11. During PY5, did your CRCCP program use some type of patient navigation data system to collect non-clinical data about navigation
services delivered?
Yes
No
12. During PY5, did your CRCCP program collect CCDE data for non-CRCCP clients who received navigation/case management?
Yes
No
13. During PY5, did your CRCCP encounter challenges related to accessing CCDE data for non-CRCCP clients who received navigation/case
management?
Yes
No
C. Patient Recruitment (outreach and clinic in-reach) for Screening Provision
1. What is the geographic reach of each resource listed below, to recruit patients for screening provision provided For every row item, check all
that apply. If you do not have an “other” then you must still check, “NA.”
Note: “In-reach,” in the questions below, means direct/indirect targeting of an established patient or client population.

Regional

State/Tribewide

Multicounty/
tribe

Single
county/
tribe

City/local

Community- NA - We do
specific e.g., not use this
neighborhood
resource

a. In-reach recruitment (e.g.,
recruiting patients of an existing
program like the NBCCEDP or
patients of a clinic)
b. Community health workers
c. Community-based organizations
d. Faith-based organizations

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e. Public health nurses at local level
f. IHS Tribal Health Clinic or Board
g. Non-IHS Tribal Health Clinic or
Board
h.
Other,
please
specify
2. What clinic in-reach activities are conducted to provide information and education about the screening provision provided through ?
(Check all that apply.)
Distribution of brochures about colorectal cancer screening
Tailored letters or communication from health care provider
Flyers and information about posted in clinic/hospital/health care center
Pre-reviewing records/charts to identify patients eligible for screening provision and tagging charts for providers
Other (describe)
None. does not conduct clinic in-reach activities to recruit patients for screening provided
D. Professional Development, Quality Assurance and Quality Improvement
The following questions ask about professional development/provider education and quality assurance (QA)/quality improvement (QI) activities
that your organization provided in program year 5 (PY5) as part of your screening provision .
1. Who was the primary target audience for your professional development/provider education activities in PY5?
(Check all that apply.)
Examples of activities may include providing continuing medical education (CME) opportunities, distributing physician tool kits, screening
guidelines, or conducting webcasts, among other activities.
Endoscopists/gastroenterologists (GIs)
PCPs/internal medicine specialists/family practice providers/OB-GYN doctors
Nurses
Nurse practitioners/physician assistants
Medical assistants
Staff at local health department clinics
Other, please specify
NA – We did not provide any professional development/provider education activities in PY5
1a. We are interested in learning about professional development activities around CRC in your state/tribal area even if your organization did
not provide them. Please use this space to describe these other professional development activities around CRC that you may know of in
your state/tribal area, if any.




For the next questions you will be asked to indicate the types of professional development/provider education provided by your as part of the
screening provision component in program year 5 (PY5). For each type of activity you specify, you will then be asked some additional question
to tell us more about that activity.
2. Did your CRCCP provide continuing medical education opportunities (e.g., at physician conferences, through webinars, presentations)
as part of the screening provision component in PY5?
Yes
No
Please tell us more about the continuing medical education (CME) opportunities your offers as part of the screening provision component.
2a. Generally, how frequently were your CMEs offered?
time(s) per -- Select One --



2b. Please describe the CME content.



2c. Who provided the CME training?
(Check all that apply.)
Medical Advisory Board members
Grantee staff
Contractor
State or tribal medical organization
Other, please specify
3. Did your CRCCP distribute or provide physician education materials (not including CRC screening guidelines) as part of the screening
provision component in PY5? Examples of physician education materials include brochures, education outreach visits (not academic

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detailing), webcasts, and physician tool kits, among other materials.
Yes
No
3a. Did your CRCCP distribute brochures for professional development as part of the screening provision component?
Yes
No
3a.i. Generally, how frequently were these brochures distributed (across all clinic sites)?
time(s) per -- Select One --



3a.ii. Please describe the brochure content.



3a.iii. Who provided these materials?
(Check all that apply.)
Medical Advisory Board members
Grantee staff
Contractor
State or tribal medical organization
Other, please specify
3b. Did your CRCCP conduct education outreach visits or webcasts for professional development as part of the screening provision
component?
Yes
No
3b.i. Generally, what was the frequency of educational outreach visits or webcasts?
time(s) per -- Select One --



3b.ii. Please describe the content of the outreach visits or webcasts.



3b.iii. Who conducted or provided the visits or webcasts?
(Check all that apply.)
Medical Advisory Board members
Grantee staff
Contractor
State or tribal medical organization
Other, please specify
3c. Did your CRCCP distribute physician tool kits or programs, such as the National Colorectal Cancer Round Table Provider Kit, for
professional development as part of the screening provision component?
Yes
No
3c.i. Generally, how frequently were these toolkits or programs distributed (across all clinic sites)?
time(s) per -- Select One --



3c.ii. Please describe the tool kit or program content.



3c.iii. Who provided the kit(s) or program(s)?
(Check all that apply.)
Medical Advisory Board members
Grantee staff
Contractor
State or tribal medical organization
Other, please specify
3d. Did your CRCCP distribute any other physician education materials for professional development as part of the screening provision
component?
Yes
No
3di. Generally, how frequently were these other physician education materials distributed (across all clinic sites)?

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

3d.ii. Please describe these other physician education materials that are distributed as part of your screening provision component.



3d.iii. Who provided these other materials?
(Check all that apply.)
Medical Advisory Board members
Grantee staff
Contractor
State or tribal medical organization
Other, please specify
4. Did your CRCCP distribute clinical guidelines for CRC screening as part of the screening provision component in PY5?
Yes
No
4a. Generally, how frequently were these clinical guidelines for CRC screening distributed (across all clinic sites)?
time(s) per -- Select One --



4b. Please indicate which guideline(s) were distributed.
(Check all that apply.)
US Preventive Services Task Force
American Cancer Society
Multi-Society Task Force- CRC
American College of Radiology Guidelines
American College of Gastroenterology
National Comprehensive Cancer Network
Other, please specify
4c. Please describe the guidelines that were distributed as part of your screening provision component.



4d. Who distributed the guidelines?
(Check all that apply.)
Medical Advisory Board members
Grantee staff
Contractor
State or tribal medical organization
Other, please specify
5. Did your CRCCP provide any other type of professional development/provider education as part of the screening provision
component in PY5?
Yes
No
5a. Generally, how frequently were these other types of professional development materials or activities provided (across all clinic sites)?
time(s) per -- Select One --



5b. Please describe these other types of professional development materials or activities that are provided as part of your screening
provision component.



5c. Who provided these other types of professional development materials or activities?
(Check all that apply.)
Medical Advisory Board members
Grantee staff
Contractor
State or tribal medical organization
Other, please specify
For the next questions you will be asked to indicate the types of quality assurance (QA)/quality improvement(QI) activities that your
organization provided as part of your screening provision component during program year 5 (PY5). For each type of activity you specify, you
will then be asked some additional questions to tell us more about that activity.
6. Who was the primary target audience for your QA/QI activities in PY5?
(Check all that apply.)

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QA/QI activities include academic detail (i.e. educational outreach for physicians), collecting and monitoring screening data, and performance
monitoring.
Endoscopists/gastroenterologists (GIs)
PCPs/internal medicine specialists/family practice providers/OB-GYN doctors
Nurses
Nurse practitioners/physician assistants
Medical assistants
Staff at local health department clinics
Other, please specify
N/A - We do not provide any QA/QI activities

7. Did your CRCCP provide academic detailing as part of your screening provision component in PY5?
Academic detailing is educational outreach for physicians. Academic detailing is intended to support clinical decision making by providing
accurate, up-to-date synthesis of relevant clinical information to physicians in a balanced and engaging format.
Yes
No
Please tell us more about the academic detailing opportunities that your offered as part of the screening provision component.
7a. Generally, how frequently was academic detailing provided (across all clinic sites)?
time(s) per -- Select One --



7b. Please describe the academic detail provided as part of your screening provision component.



7c. Where was the academic detailing provided?



7d. Who provided the academic detailing?
(Check all that apply.)
Medical Advisory Board members
Grantee staff
Contractor
State or tribal medical organization
Other, please specify
8. Did your CRCCP collect and monitor clinical data OTHER than the required CCDEs for screening or patient navigation in PY5?
Yes
No
Please tell us more about these clinical data collecting and monitoring activities that your conducted as part of the screening provision
component.
8a. Generally, how frequently were these data on screening provision or patient navigation collected and monitored (across all clinic sites)?
time(s) per -- Select One --



8b. Please describe these data collection and monitoring activities that you conducted for either screening or patient navigation.



9. Did your CRCCP produce provider-level performance monitoring reports (e.g., using CCDE data to produce screening quality indicator
reports) and feed them back to your providers as part of your screening provision component in PY5? Performance monitoring involves using
data to assess performance on specified indicators of performance.
Yes
No
Please tell us more about the performance monitoring activities that your conducted as part of the screening provision component.
9a. Generally, how often were performance monitoring reports given back to your providers (across all clinic sites)?
time(s) per -- Select One --



9b. Please describe these performance monitoring reports that you produced and gave to your providers as part of your screening
provision component.




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10. We are interested in learning more about QA/QI activities around CRC in your state/tribal area, even if your organization was not
involved in them. Please describe the other QA/QI activities around CRC that you may know of in your state/tribal area, if any.



E. Other Population-based CRC Screening Provision Activities and Support
1. Were there any other programs in your state/tribal area, in addition to CRCCP, that offered or supported CRC screening provision for the
underinsured or uninsured during program year 5 (PY5), excluding Medicaid/Medicare or other resources related to the Affordable Care
Act?
Yes
No
1a. Please describe the other program(s) in your state/tribal area that offered CRC screening provision for the underinsured or uninsured in
PY5. Please describe the program reach and activities.



2. Did your organization receive financial resources other than those from CDC to support CRC screening provision in PY5?
Yes
No
2a. Describe the sources and amount of funds (other than CDC) that your organization used to support CRC screening provision from July 1,
2013 through June 30, 2014, and check the activities that were supported by those funds.

Funding
source

Promoting
quality
Identifying
assurance
Implementing Facilitating
and
(QA)/quality
or supporting
access to
contracting
improvement
the use of
treatment
Providing
with
(QI)
Identifying
patient
for
screening physicians
Providing or
standards
and
navigation/case
cancers
and
or clinics
promoting
among
recruiting
management
diagnosed
diagnostic to deliver
professional
funded
patients
services for
through
Approximate services
screening development/provider
provider
for CRCCP
screening
your
Amount
directly
services
education
sites
screening
provision
CRCCP

Check here, if you did not receive additional funds (non-CDC) to support CRC screening provision during July 1, 2013 - June 30, 2014
2a.i.
2a.ii.
2a.iii.

H. Eligibility for CRC Screening Provision
Please answer the following questions about eligibility for screening provision through your CRCCP for the program year 5 (PY5; 7/01/136/30/14).
1. What Federal Poverty Level was used to determine eligibility for CRC screening?
250%
200%
Other, please specify:

%

2. What percentage of clients screened by your CRCCP had some form of insurance coverage? Write in % or Don't Know
%
3. Did your CRCCP require clients to provide any type of verification that they were uninsured or underinsured?
Yes
No
4. Did your CRCCP restrict program eligibility to any of the following groups?
(Check all that apply.)
US citizens only
Legal residents of state or territory
Members or defined affiliation with Tribe/tribal council
Others, please specify:
Program eligibility varies by provider site
N/A - None
5. Did any of your CRCCP program eligibility criteria change during the reporting period, (PY5)?
Yes
No
5a. Which program eligibility criteria changed? (Check all that apply.)

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Federal Poverty level
Insurance status
Citizenship/residency/Tribal affiliation
Other, please specify:
5b. Why did you change your eligibility criteria?
(Check all that apply.)
To reduce the number of adults eligible for CRC screening
To increase the number of adults eligible for CRC screening
Funding limitations or reductions
Expected impact of health reform
Change in state/territory/tribe regulation
Other, please specify:
7. During PY5, did your CRCCP program facilitate men/women’s enrollment in insurance coverage for colorectal cancer screening services?
Yes, our CRCCP facilitated enrollment in Medicaid
Yes, our CRCCP facilitated enrollment in Medicare
Yes, our CRCCP facilitated enrollment in IHS
Yes, our CRCCP facilitated enrollment in State-based insurance
Yes, our CRCCP facilitated enrollment in Insurance marketplace
Yes, our CRCCP facilitated enrollment, but I do not know the specific insurance sources
No
8. During PY5, what activities did your CRCCP program conduct in order to facilitate men/women’s enrollment in insurance coverage?
(Check all that apply)
Provided women information about sources of insurance coverage and related contact information (e.g., refer to website for the
Insurance Marketplace, provide Medicaid enrollment office phone number)
Conducted assessments of men/women to see if they met eligibility criteria for insurance coverage through specific sources such as
Medicaid, Medicare, IHS, State-based Insurance, Insurance Marketplace
Provided assistance to men/women to complete insurance enrollment processes
Tracked and followed-up with women to see if they successfully enrolled in insurance coverage
Other:
9. During PY5, did you count the number of men/women that your CRCCP program referred for insurance coverage?
Yes
No
9.a. how many women did your CRCCP program refer for insurance coverage in PY5?

10. How useful have you found the following technical assistance resources provided by CDC?
N/A - did
not use

Very
useful

Somewhat
useful

Not useful

CDC Webinars (e.g., QSST, PETO)
Printed guide: An Action Guide for Working with Health Systems
Printed guide: An Action Guide for Engaging Employers and Professional Medical
Organizations
ACA reference guide and fact sheets
ACA messaging tool
On-going technical assistance provided by PCs

11. Has your CRCCP program developed tools related to health reform that may be useful to others?
Yes
No
11.a. Please describe the tools related to health reform that may be useful to others.



G. Other Comments – CRC Screening Provision
1. What else would you like us to know about your organization’s CRC Screening Provision efforts, including CRCCP screening provision
activities funded or supported by sources other than CDC?



SECTION 3 – CRC SCREENING PROMOTION
This section asks about your CRCCP’s CRC screening promotion activities to increase population-based screening implemented during
program year 5 (PY5). The questions focus primarily on your CRCCP’s use of each of the five strategies recommended by the Community Guide

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to increase CRC screening broadly in the population (rather than strategies focused solely on persons screened through the program); these five
strategies include:
1)
2)
3)
4)
5)

Small media
Patient or client reminders
Provider reminders
Reducing structural barriers
Provider assessment and feedback

We also ask you to describe partner involvement, if any, in your implementation of each strategy.
Q1. Please describe one of your organization's major screening promotion goals or objectives for the report year (PY5: July 1, 2013 – June 30,
2014).



Q2. What was the priority population your organization was trying to reach through the screening promotion goal or objective you described
(aside from people meeting program eligibility requirements)



A. Small Media for Screening Promotion
Small media include videos and printed materials such as letters, brochures, flyers, and newsletters used to inform and motivate people to be
screened for colorectal cancer. Small media can provide information tailored to specific or general audiences.
The following questions ask about small media activities for CRC screening promotion that have been implemented as a part of
the CRCCP in program year 5 (PY5).
1. Did your organization use small media to promote colorectal cancer screening in PY5?
“Your organization” refers to you, your contractors, and other partners.
Yes, we currently use small media to promote CRC screening
No, we do not currently use small media to promote CRC screening, but we used it in the past (i.e. during any current or previous
CRCCP contract year).
No, we have never used small media.
No, we have never used small media to promote CRC screening, and we are not planning or intend to use small media in the next 12
months.
1a. What are the main reasons your organization has not used small media to promote CRC screening, to date?



1b. Please describe your CRCCP’s previous attempts at using small media to promote CRC screening, including:
- For how long you implemented it
- Partner involvement (if any)
- What type of small media was used (e.g. flyers, brochures, videos, etc.)
- Where the materials were distributed (e.g. provider offices, FQHCs, DOH, etc.)



1c. Why did your organization stop using small media to promote CRC screening?



2. For how long has your organization been using small media to promote colorectal cancer screening?
Less than 6 months
6-11 months
1-2 years
3-4 years
5 years or more
3. Has your organization used any of the following resources to create small media as part of your CRC screening promotion activities?
(Check all that apply.)
MIYO (Make It Your Own)
CDC’s Screen for Life
Other, please specify
No, we have not used any of these resources to create small media to promote CRC screening
3a. Please describe the CDC Screen for Life materials you used, to create small media as part of your CRC screening promotion activities.

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

6. Where did your organization use each of the small media types listed in the table below, to promote CRC screening?
For every row item, check all that apply. If you do not have an “other” then you must still check, “NA.”

Local
Individual
Health
Dept
Physician’s Provider
Care
Insurance
of
Office
Group Systems FQHCs Medicare Medicaid providers Health Workplace

Community
eg. CBOs,
faith
groups,
library

NA – We
don't use
this to
promote
CRC
screening

Small Media Type
Videos
Flyers or posters
Brochures, booklets or FAQs
Newsletters, inserts or bookmarks
Checklists or questions to ask
providers
Other leave behinds, e.g. tip sheets
or business cards
Electronic media, e.g. text, social
media tools (Twitter, Facebook, etc),
websites
Other,
please
specify
7. What geographic areas best describe the intended geographic reach of each small media type used by your organization to promote CRC
screening?
For every row item, check all that apply. If you do not have an “other” then you must still check, “NA.”

Multistate

State/Tribewide

MultiCounty or
MultiTribe

Single
County or
Tribe

City/local

Communityspecific
(Neighborhood)

NA – We
didn't use
this to
promote
CRC
screening

Small Media Type
Videos
Flyers or posters
Brochures, booklets or FAQs
Newsletters, inserts or bookmarks
Checklists or questions to ask
providers
Other leave behinds, e.g. tip sheets
or business cards
Electronic media, e.g. text, social
media tools (Twitter, Facebook, etc),
websites
Other,
please
specify

Small Media - Partners
8. How many partner organizations (e.g., non-funded partners, contractors) did you work with to implement small media activities or
disseminate small media materials to promote CRC screening in PY5?
partners
None, we do not partner with any organizations to implement small media activities or disseminate small media materials to
promote CRC screening
8a. Describe why partners were not used as part of your implementation of small media.



10. Which of the following best describes the partner organization(s) you worked with to promote CRC screening through small media in
PY5?

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(Check all that apply.)
Academic institution
Advocacy group/ Community-based organization/Community or health coalition
American Cancer Society
Another grantee
Comprehensive Cancer Control Coalition
Chronic Disease programs within your agency
Employers/worksites
Federally qualified health center (FQHC)
Indian Health Service (IHS) clinic or board, IHS Urban Indian health clinic
Individual health care provider/single practice
Local health department(s)
Medicare Quality Improvement Organization (QIO) office
Non-IHS tribal clinic, board, or health care facility
Private and/or non-profit health care system
Private health insurer
Professional organization (e.g., primary care provider association in your state, state medical office)
Quality assurance organization
State Medicaid Office
State Office of Rural Health
Tribal council
Other (please specify)
10a. For each geographic designation in the table below, please specify the number of partner organizations who used small media in that
area to promote CRC screening in PY5.
Please enter the appropriate numeric value or "don't know".
Enter "0" if no partners used this EBI in PY5 in the designated area.
Geographic Designation

# of partners using small

Definition

media in this area

10ai. Large Metro
Counties with a population of 1 million or more
10aii. Medium Metro
Counties with a population of 250,000-999,999
10aiii. Small Metro
Counties with a population of 50,000-249,999
10aiv. Micropolitan
Counties of less than 50,000 that contain all or
part of a city of at least 10,000 or more residents
10av. Rural
Counties that do not contain any part of a city of
10,000 or more residents
10avi. Multiple counties or statewide
10b. Did your CRCCP distribute small media materials as an enhancement to, or as a part of any of the following activities during PY5?
(Check all that apply.)
Patient navigation (e.g., a navigator gives a patient an educational brochure in addition to addressing other barriers)
Client reminders (e.g., a postcard sent to a client to remind them that they are due for screening also includes a general
educational message about screening)
One-on-one education (e.g., a health worker gives a brochure to a community member during outreach)
Group education (e.g., a health educator distributes brochures as part of an educational session)
Other, please specify:
NA - We did not distribute small media as an enhancement to, or as a part of any of the above activities during PY5
Ease or Difficulty of Small Media Implementation for CRC Screening Promotion

17. Thinking about the small media intervention activities that your organization implemented in PY5, rate the level of ease or difficulty
it took to implement them on average.
Very easy to
implement

Somewhat
easy

Neutral

Somewhat
difficult

Very difficult
to implement

B. Patient or Client Reminders for Population-level CRC Screening Promotion
Patient or client reminders include letters, postcards, or phone calls to alert patients that it is time for their cancer screening. Some reminders
note only that the test is due, while other reminders include facts about the screening or offer to help set up an appointment, in addition to
including a reminder that the test is due.
The following questions ask about patient or client reminder systems for CRC screening promotion that have been implemented
as a part of the CRCCP in program year 5 (PY5).

1. Does your organization use patient or client reminders to promote colorectal cancer screening?
“Your organization” refers to you, your contractors and other partners.

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Yes, we currently use patient reminders or client reminders to promote CRC screening
No, we do not currently use patient or client reminders to promote CRC screening, but we used to in the past (i.e. during any current or
previous CRCCP contract year).
No, we have never used patient or client reminders.
No, we have never used patient or client reminders, and we are not planning or intend to use it in the next 12 months.
1a. What are the main reasons your organization has not used patient or client reminders to promote CRC screening, to date?



1b. Please describe your organization’s previous attempts at using patient or client reminders to promote CRC screening, including:
- For how long you implemented it
- Partner involvement (if any)
- What type of patient or client reminders were used
- Where they were distributed (e.g. provider offices, FQHCs, DOH, etc.).



1c. Why did your organization stop using patient or client reminders to promote CRC screening?



2. For how long has your organization been using patient or client reminders to promote colorectal cancer screening?
Less than 6 months
6-11 months
1-2 years
3-4 years
5 years or more
3. Has your organization used any of the following resources to create patient or client reminders as part of your organization’s CRC
screening promotion activities?
(Check all that apply.)
MIYO (Make It Your Own)
Other, please specify
No, we have not used any of these resources to create patient or client reminders as part of our screening promotion activities
6. Do you use any of the following types of patient or client reminders as a part of your CRCCP screening promotion efforts?
Mailed postcards, letters, or greeting cards?
Telephone, texts, or email messages?
6.a.i. Which types of organizations have implemented reminder systems using post cards, letters, or greeting cards based on your
program efforts?
(Check all that apply.)
Individual physician’s office
IHS or tribal clinic
Provider group (several or many physicians)
FQHCs
Health care system
Health insurer
Medicare Quality Improvement Organization (QIO) office
State Medicaid Office
My (We implement these reminder systems, ourselves.)
Other, please specify
6.b.i. Which types of organizations have implemented reminder systems using telephone, text, or email messages based on your program
efforts?
(Check all that apply.)
Individual physician’s office
IHS or tribal clinic
Provider group (several or many physicians)
FQHCs
Health care system
Health insurer
Medicare Quality Improvement Organization (QIO) office
State Medicaid Office
My (We implement these reminder systems, ourselves)
Other, please specify
Patient or Client Reminders - Partners

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7. How many partner organizations (e.g. non-funded partners, did do you work with to implement patient or client reminder activities to
promote CRC screening in PY5?
partners
None. We did not partner with any organizations to implement or disseminate patient reminders to promote CRC screening.
7.a. Describe why partners were not used as part of your patient reminder efforts for CRC screening.



9. Which of the following best describes the partner organization(s) you worked with to promote CRC screening using patient reminders
in PY5?
(Check all that apply.)
Academic institution
Advocacy group/ Community-based organization/Community or health coalition
American Cancer Society
Another Grantee
Chronic Disease programs within your agency
Comprehensive Cancer Control Coalition
Employers/worksites
Federally qualified health center (FQHC)
Indian Health Service (IHS) clinic or board, IHS Urban Indian health clinic
Individual health care provider/single practice
Local health department(s)
Medicare Quality Improvement Organization (QIO) office
Non-IHS tribal clinic, board, or health care facility
Private and/or non-profit health care system
Private health insurer
Professional organization (e.g., primary care provider association in your state, state medical office)
Quality assurance organization
State Medicaid office
State office of rural health
Tribal council
Other (please specify)
9.a. For each geographic designation in the table below, please specify the number of partners that used patient or client reminders in that
area to promote CRC screening in PY5.
Please enter the appropriate numeric value or "don't know".
Enter "0" if no partners used this EBI in PY5 in the designated area.

Geographic Designation

# of partners using provider

Definition

reminders in this area

9ai. Large Metro
Counties with a population of 1 million or more
9aii. Medium Metro
Counties with a population of 250,000-999,999
9aiii. Small Metro
Counties with a population of 50,000-249,999
9aiv. Micropolitan
Counties of less than 50,000 that contain all or
part of a city of at least 10,000 or more residents
9av. Rural
Counties that do not contain any part of a city of
10,000 or more residents
9avi. Multiple counties or statewide
Ease or Difficulty of Implementing Patient or Client Reminders for CRC Screening Promotion
18. Thinking about the patient or client reminder activities that your organization implemented in PY5, rate the level of ease or
difficulty it took to implement them on average.
Very easy to
implement

Somewhat
easy

Neutral

Somewhat
difficult

Very difficult
to implement

C. Provider Reminders for CRC Screening Promotion
Provider reminders inform health care providers that it is time for a client’s cancer screening test (called a “reminder”) or that the client is
overdue for screening (called a “recall”). The reminders can be provided in different ways, such as flagging client charts, building provider
reminders into electronic medical record systems or provider office appointment systems, or by e-mail to the provider.
The following questions ask about provider reminder activities for CRC screening promotion that have been implemented as a
part of the CRCCP in program year 5 (PY5).
1. Did your organization use provider reminders to promote colorectal cancer screening in PY5?

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“Your organization” refers to you, your contractors and/or partners that you work with to implement provider reminders for
CRC screening promotion.
Yes, we currently use provider reminders to promote CRC screening
No, we do not currently use provider reminders to promote CRC screening, but we used to in the past (i.e. during any current or
previous CRCCP contract year).
No, we have never used provider reminders.
No, we have never used provider reminders to promote CRC screening, and we are not planning or intend to do use them in the next 12
months
1.a. What are the main reasons your organization has not used provider reminders to promote CRC screening, to date?



1.b. Please describe your organization's previous attempts at using provider reminders to promote CRC screening, including:
- For how long you implemented it
- Partner involvement (if any)
- What type of provider reminders were used
- Where they were distributed (e.g. provider offices, FQHCs, DOH, etc.).



1.c. Why did your organization stop using provider reminders to promote CRC screening?



2. For how long has your organization been using provider reminders to promote colorectal cancer screening?
Less than 6 months
6-11 months
1-2 years
3-4 years
5 years or more
5. Did you use any of the following types of provider reminders as a part of your organization’s screening promotion efforts in PY5?
(Check all that apply.)
Patient chart reminders
Provider reminders built into electronic medical record (EMR) systems?
Other types of provider reminders, please describe:
5.a.i. Where were chart reminders used?
(Check all that apply.)
Individual physician’s office
IHS or tribal clinic
Provider group
FQHCs
Health care system
My (We implement these reminder systems, ourselves.)
Other, please specify
5.a.ii. How many clinic sites implemented chart reminders during PY5? [write-in # or Don't Know]

5.b.i. Where were EMR-based provider reminders used?
(Check all that apply.)
Individual physician’s office
IHS or tribal clinic
Provider group
FQHCs
Health care system
My (We implement these reminder systems, ourselves.)
Other, please specify
5.b.ii. How many clinic sites implemented provider reminders using an EMR during PY5? (write-in # or Don't Know)

5.c.i. Where were the other provider reminders you mentioned used?
(Check all that apply.)
Individual physician’s office
IHS clinic or tribe
Provider group
FQHCs

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Health care system
My (We implement these reminder systems, ourselves.)
Other, please specify
5.c.ii. How many clinic sites implemented any of these other provider reminders in PY5? [write-in # or Don't Know]

Provider Reminders - Partners
6. How many partner organizations did your organization work with to implement provider reminder systems to promote CRC screening in
PY5?
partners
None, we did not partner with any organizations to implement provider reminder systems to promote CRC screening
6a. Describe why partners were not used as part of your efforts to use providers reminders to promote CRC screening.



8. Which of the following best describes the partner organization(s) you worked with to promote CRC screening, using provider reminder
systems in PY5?
(Check all that apply.)
Academic institution
Advocacy group/ Community-based organization/Community or health coalition
American Cancer Society
Another Grantee
Chronic Disease programs within your agency
Comprehensive Cancer Control Coalition
Employers/worksites
Federally qualified health center (FQHC)
Indian Health Service (IHS) Clinic or Board, IHS Urban Indian health clinic
Individual health care provider/single practice
Local health department(s)
Medicare Quality Improvement Organization (QIO) office
Non-IHS tribal clinic, board, or health care facility
Private and/or non-profit health care system
Private health insurer
Professional organization (e.g., primary care provider association in your state, state medical office)
Quality assurance organization
State Medicaid office
State office of rural health
Tribal council
Other (please specify)
8a. For each geographic designation in the table below, please specify the number of partner sites that used provider reminder systems in
that area to promote CRC screening in PY5.
Please enter the appropriate numeric value or "don't know".
Enter "0" if no partners used this EBI in PY5 in the designated area.

Geographic Designation

# of partner sites using provider

Definition

reminders in this area

8ai. Large Metro
Counties with a population of 1 million or more
8aii. Medium Metro
Counties with a population of 250,000-999,999
8aiii. Small Metro
Counties with a population of 50,000-249,999
8aiv. Micropolitan
Counties of less than 50,000 that contain all or
part of a city of at least 10,000 or more residents
8av. Rural
Counties that do not contain any part of a city of
10,000 or more residents
8avi. Multiple counties or statewide
Ease or Difficulty of Implementing Provider Reminders for CRC Screening Promotion
17. Thinking about the provider reminder activities that your organization implemented in PY5, rate the level of ease or difficulty it took
to implement them on average.
Very easy to
implement

Somewhat
easy

Neutral

Somewhat
difficult

Very difficult
to implement

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E. Provider Assessment and Feedback for CRC Screening Promotion
Provider assessment and feedback interventions both evaluate provider performance in delivering or offering screening to clients (assessment)
and present providers with information about their performance in providing screening services (feedback).
Feedback may describe the performance of a group of providers (e.g., average performance for a practice) or an individual provider, and may
or may not be compared with a goal or standard.
The following questions ask about provider assessment and feedback systems for CRC screening promotion that have been
implemented as a part of the CRCCP during program year 5 (PY5).
1. Did your organization offer provider assessment and feedback to promote colorectal cancer screening in PY5?
Your organization” refers to you, your contractors and/or partners.
Yes, we used provider assessment and feedback for CRC screening promotion in PY5.
No, we did not use provider assessment and feedback for CRC screening in PY5, but we have in the past (i.e. during any previous
CRCCP contract year).
No, we have never used provider assessment and feedback for CRC screening promotion.
1a. What are the main reasons your organization has not used provider assessment and feedback to promote CRC screening, to date?



1b. Please describe your organization's previous attempts at using provider assessment and feedback to promote CRC screening,
including:
- For how long you implemented it
- Partner involvement (if any)
- What type of provider assessment feedback were used



1c. Why did your organization stop using provider assessment and feedback to promote CRC screening?



2. For how long has your organization been using provider assessment and feedback for colorectal cancer screening promotion?
Less than 6 months
6-11 months
1-2 years
3-4 years
5 years or more
5. Did you use any of the following types of provider assessment and feedback as a part of your CRCCP screening promotion efforts in
PY5?
(Check all that apply.)
Evaluating provider performance in delivering or offering screening to clients (assessment).
Presenting providers with information about their performance in providing screening services (feedback).
5.a.i. Please describe your provider assessment efforts, including what’s being assessed, how you’ve been conducting the assessment, and
how those efforts have been going, to date.



5.a.ii. Where is the provider assessment being used?
(Check all that apply.)
FQHCs
Health care system
Insurer
IHS or tribal clinic
Individual physician’s office
Provider group
My organization
Other, please specify

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5.b.i. Please describe your provider feedback efforts, including what type of feedback is provided, how you’ve been delivering the
feedback, and how those efforts have been going, to date.



5.b.ii. Where is the provider feedback being used?
(Check all that apply.)
FQHCs
Health care system
Insurer
IHS or tribal clinic
Individual physician’s office
Provider group
My organization
Other, please specify
Provider Assessment and Feedback - Partners
6. How many partner organizations did your organization work with to implement provider assessment and feedback systems, to promote
CRC screening in PY5?
partners
None, we did not partner with any organizations to implement provider assessment and feedback systems to promote CRC screening.
6a. Describe why partners are not used as part of your efforts to use provider assessment and feedback for CRC screening promotion.



8. Which of the following best describes the partner organization(s) you worked with to promote CRC screening using provider
assessment and feedback in PY5?
(Check all that apply.)
Academic institution
Advocacy group/ Community-based organization/Community or health coalition
American Cancer Society
Another grantee
Chronic Disease programs within your agency
Comprehensive Cancer Control Coalition
Employers/worksites
Federally qualified health center (FQHC)
Indian Health Service (IHS) clinic or board, IHS Urban Indian health clinic
Individual health care provider/single practice
Local health department(s)
Medicare Quality Improvement Organization (QIO) office
Non-IHS tribal clinic, board, or health care facility
Private and/or non-profit health care system
Private health insurer
Professional organization (e.g., primary care provider association in your state, state medical office)
Quality assurance organization
State Medicaid office
State office of rural health
Tribal council
Other (please specify)
8a. For each geographic designation in the table below, please specify the number of partner sites that used provider assessment and
feedback in that area to promote CRC screening in PY5.
Please enter the appropriate numeric value or "don't know".
Enter "0" if no partners used this EBI in PY5 in the designated area.

Geographic Designation
Definition

# of partner sites using
provider assessment and
feedback in this area

8ai. Large Metro
Counties with a population of 1 million or more
8aii. Medium Metro
Counties with a population of 250,000-999,999
8aiii. Small Metro
Counties with a population of 50,000-249,999
8aiv. Micropolitan
Counties of less than 50,000 that contain all or
part of a city of at least 10,000 or more residents
8av. Rural
Counties that do not contain any part of a city of
10,000 or more residents

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8avi. Multiple counties or statewide
Ease or Difficulty of Implementing Provider Assessment and Feedback Activities for CRC Screening Promotion
15. Thinking about the provider and assessment activities for CRC screening promotion that your organization implemented in PY5, rate
the level of ease or difficulty it took to implement them on average.
Very easy to
implement

Somewhat
easy

Neutral

Somewhat
difficult

Very difficult
to implement

D. Reducing Structural Barriers for CRC Screening Promotion
Structural barriers are non-economic burdens or obstacles that make it difficult for people to access cancer screening. Interventions designed to
reduce these barriers may facilitate access by:
Reducing time or distance between service delivery settings and target populations
Modifying hours of service to meet client needs
Offering services in alternative or non-clinical settings
Eliminating or simplifying administrative procedures and other obstacles (e.g., revising clinic flow procedures, adopting electronic medical
records systems).
The following questions ask about interventions that have been implemented to reduce structural barriers for CRC screening
promotion in program year 5 (PY5).
1. Did your organization use interventions to reduce structural barriers to promote colorectal cancer screening in PY5?
Please note: Patient Navigation Services that specifically assist with transportation, language translation and/or dependent care should be
included here; The Community Guide has identified these activities as examples of reducing structural barriers. All other patient navigation
services for screening promotion are asked about in the Patient Navigation for Screening Promotion Section of the survey.
Yes, we currently use interventions to reduce structural barriers to promote CRC screening.
No, we do not currently use interventions to reduce structural barriers to promote CRC screening, but we used to in the past (i.e. during
any current or previous CRCCP contract year).
No, we have never used interventions to reduce structural barriers to promote colorectal cancer screening in PY5....
No, we have never used interventions to reduce structural barriers to promote CRC screening, and we are not planning or intend to use
them in the next 12 months.
1.a. What are the main reasons your organization has not used interventions to reduce structural barriers to promote CRC screening, to
date?



1.b. Please describe your CRCCP’s previous attempts at reducing structural barriers to promote CRC screening, including:
-For how long you implemented the strategy
-Partner involvement (if any)
-What type of structural barriers were addressed.



1.c. Why did your CRCCP stop using interventions to reduce structural barriers to promote CRC screening?



2. For how long has your organization been reducing structural barriers to promote colorectal cancer screening?
Less than 6 months
6-11 months
1-2 years
3-4 years
5 years or more
3. Which strategies for reducing structural barriers does your organization use?
(Check all that apply.)
Reducing time or distance between service delivery settings and target populations
Modifying hours of service to meet client needs
Offering services in alternative or non-clinical settings
Eliminating or simplifying administrative procedures and other obstacles
Providing clients assistance with transportation, language assistance, child/eldercare (e.g., patient navigation/case management)
Other (please specify)
5. Did your organization conduct any assessment of structural barriers before implementing strategies to reduce structural barriers to
promote your CRC screening activities?
Yes

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No
5.a. Please describe the structural barrier assessment(s) that your organization conducted prior to implementing strategies to reduce
them, to promote your CRC screening activities.



Reducing Structural Barriers - Partners
7. How many organizations did your organization partner with to reduce structural barriers to promote CRC screening in PY5?
partners
None. We did not partner with any organizations to reduce structural barriers to promote CRC screening.
7.a. Describe why partners were not used as part of your efforts to reduce structural barriers, to promote CRC screening.



9. Which of the following best describes the partner organization(s) you worked with to promote CRC screening by reducing structural
barriers in PY5?
(Check all that apply.)
Academic institution
Advocacy group/ Community-based organization/Community or health coalition
American Cancer Society
Another grantee
Chronic Disease programs within your agency
Comprehensive Cancer Control Coalition
Employers/worksites
Federally qualified health center (FQHC)
Indian Health Service (IHS) clinic or board, IHS Urban Indian health clinic
Individual health care provider/single practice
Local health department(s)
Medicare Quality Improvement Organization (QIO) office
Non-IHS tribal clinic, board, or health care facility
Private and/or non-profit health care system
Private health insurer
Professional organization (e.g., primary care provider association in your state, state medical office)
Quality assurance organization
State Medicaid Office
State Office of Rural Health
Tribal council
Other (please specify)
9a. For each geographic designation in the table below, please specify the number of organizations your CRCCP partnered with to promote
CRC screening by reducing structural barriers in that area during PY5.
Please enter the appropriate numeric value or "don't know".
Enter "0" if no partners used this EBI in PY5 in the designated area.

Geographic Designation

# of partners conducting activities to

Definition

reduce structural barriers in this area

9ai. Large Metro
Counties with a population of 1 million or more
9aii. Medium Metro
Counties with a population of 250,000-999,999
9aiii. Small Metro
Counties with a population of 50,000-249,999
9aiv. Micropolitan
Counties of less than 50,000 that contain all or
part of a city of at least 10,000 or more residents
9av. Rural
Counties that do not contain any part of a city of
10,000 or more residents
9avi. Multiple counties or statewide
Ease or Difficulty of Reducing Structural Barriers for CRC Screening Promotion
16. Thinking about the activities that your organization implemented in PY5 to reduce structural barriers for CRC screening, rate the
level of ease or difficulty it took to implement them on average.
Very easy to
implement

Somewhat
easy

Neutral

Somewhat
difficult

Very difficult
to implement

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F. Patient Navigation for CRC Screening Promotion
A patient navigator guides the patient through the process of completing colorectal cancer screening by helping to reduce patient-specific
barriers. Some programs may refer to this as case management. Some roles of the patient navigator (PN) include:
Assisting with scheduling appointments, transportation, or dependent care
Providing patient education about CRC screening and testing modalities for screening (e.g., rationale, importance, bowel prep)
Reminding patients about their colonoscopy appointment or returning their FOBT/FIT kits
Providing peer support to help with cultural or emotional concerns (e.g., allay fears)

The following questions ask about your organization's support for patient navigators (PN)/case managers (CM) for CRC
screening promotion. We are interested in your support for PN/CMs in settings where you are paying for CRC screening directly
(screening provision), and in settings where you are not.
These first questions ask about the use of patient navigators or case managers in organizations other than those providers/clinics where you
are paying for CRC screening directly (screening provision).
1. Did you support the implementation of patient navigator program(s) in any organizations (e.g., FQHCs, IHS clinics) other than those
providers/clinics where you are paying for CRC screening directly (screening provision) in PY5?
Yes, we used patient navigation or case management in PY5 for CRC screening promotion in organizations other than those
providers/clinics where we were paying for CRC screening directly.
No, we did not use patient navigation or case management in PY5 to promote CRC screening in organizations other than those
providers/clinics where we were paying for CRC screening directly, but we have in the past (i.e. during any previous CRCCP contract
year).
No, we have never used patient navigation or case management for CRC screening promotion in organizations other than those
providers/clinics where we were paying for CRC screening directly.
1ai. Please describe your CRCCP's previous attempts at using patient navigation or case management in these settings to promote
population-based CRC screening, including for how long you used it, partner involvement (if any), and types of activities or services the
PN/CM was responsible for.



1aii. Why did your CRCCP stop using patient navigators or case managers to promote CRC screening in these settings?



1b. For how long has your organization supported patient navigators or case managers in organizations other than those
providers/clinics where you are paying for CRC screening directly (screening provision)?
Less than 6 months
6-11 months
1-2 years
3-4 years
5 years or more
1c. How are these patient navigators/case managers for CRC screening promotion supported?
(Check all that apply.)
Reimbursement to providers for FTE support
Per- patient navigation/case management reimbursement
Grantee staff serving as patient navigators/case managers
In- kind from a community partner/program
Other (specify)
1d. Please specify any core navigation activities that are routinely offered as part of those organizations’ CRC screening promotion
component.
(Check all that apply.)
Patient assessment of barriers to screening
Patient education (about anatomy, CRC, CRC screening, bowel prep)
Assistance with transportation, language translation, child/eldercare
Assistance with appointment setting
Assistance with identifying payment for screening
Reminder calls/emails for bowel prep and/or appointments
Reminder calls/emails for return of FOBT/FIT tests
Peer support/motivation for screening
Follow-up with client about next steps for CRC screening and ensure understanding of results provided by medical team
Community outreach to promote CRCCP and CRC screening (e.g. Linkages with health fairs and clients in community)
Clinic in-reach activities to promote CRCCP and colorectal screening, (e.g., flagging charts for medical providers for those eligible for
Program/CRC screening)
1e. We are interested in knowing more about the patient navigators/case managers that are supported in organizations other than those
providers/clinics where you are paying for CRC screening directly. In the table below, please provide the numbers to complete the following
sentence:
____________ patient navigators/case managers, or ____________ FTEs (regardless of the number of people) are supported at
____________ sites or clinics.
If your organization supports only per-patient navigation reimbursement or per-case management reimbursement, write-in "Don't
Know" (case sensitive) in each applicable field.

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Patient Navigators/Case Managers
Full Time Equivalents, i.e., FTEs (regardless of the number of people)
At

Sites/Clinics

1f. Do some or all of the patient navigators/case managers for screening promotion in these organizations also provide patient
navigation/case management support for your screening provision activities?
No
Yes. Please describe.
Don't Know
1g. About how many CRC screening patients (total) do these organizations' patient navigators/case managers support in a year?
1-100 patients
101-500 patients
501-1000 patients
1001-5000 patients
More than 5000 patients
Don't know
These next questions ask about your organization's use of patient navigators or case management to promote colorectal cancer at
provider/clinic sites where you are paying for CRC screening directly.
2. Did your organization use patient navigation (PN) or case management (CM) to promote colorectal cancer screening at provider/clinic
sites where you are paying for CRC screening directly in PY5?
Yes, we used patient navigation or case management in PY5 for CRC screening promotion at provider/clinic sites where we were paying
for CRC screening directly.
No, we have never used patient navigation or case management for CRC screening promotion.
N/A - We do not pay for CRC screening directly
2.b. Please describe your organization's previous attempts at using patient navigation or case management to promote populationbased CRC screening, including:
- For how long you used it
- Partner involvement (if any)
- Types of activities or services the PN/CM was responsible for



2.c. Why did your organization stop using patient navigation or case management to promote CRC screening?



3. For how long has your organization been using patient navigators or case managers to promote colorectal cancer screening?
Less than 6 months
6-11 months
1-2 years
3-4 years
5 years or more
4. How are these patient navigators/case managers for CRC screening promotion supported?
(Check all that apply.)
Reimbursement to providers for FTE support
Per- patient navigation/case management reimbursement
Grantee staff serving as patient navigators/case managers
In- kind from a community partner/program
Other (specify)
5. Please specify any core navigation activities that are routinely offered as part of your organization’s CRC screening promotion
component. Check all that apply
Patient assessment of barriers to screening
Patient education (about anatomy, CRC, CRC screening, bowel prep)
Assistance with transportation, language translation, child/eldercare
Assistance with appointment setting
Assistance with identifying payment for screening
Reminder calls/emails for bowel prep and/or appointments
Reminder calls/emails for return of FOBT/FIT tests
Peer support/motivation for screening
Follow-up with client about next steps for CRC screening and ensure understanding of results provided by medical team
Clinic in-reach activities to promote CRCCP and colorectal screening, (E.g. flagging charts for medical providers for those eligible for
Program/CRC screening)
Community outreach to promote CRCCP and CRC screening (E.g. Linkages with health fairs and clients in community)
6. We are interested in knowing more about the patient navigators/case managers that are supported at provider/clinic sites where you are
paying for CRC screening directly. In the table below, please provide the numbers to complete the following sentence:

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____________ patient navigators/case managers, or ____________ FTEs (regardless of the number of people) are supported at
____________ sites or clinics .
If your organization supports only per-patient navigation reimbursement or per-case management reimbursement, write-in "Don't
Know" (case sensitive) in each applicable field.
Patient Navigators/Case Managers
Full Time Equivalents, i.e., FTEs (regardless of the number of people)
At

Sites/Clinics

6. Do some or all of your patient navigators/case managers for screening promotion also provide patient navigation/case management
support for your screening provision activities?
No
Yes
Please describe how some or all of your patient navigators/case managers for screening promotion also provide patient navigation/case
management support for your screening provision activities.



7. About how many CRC screening patients (total) do your patient navigators/case managers support in a year?
1-100 patients
101-500 patients
501-1000 patients
1001-5000 patients
More than 5000 patients
Don't know
Patient Navigation - Partners
8. How many organizations did you partner with to implement patient navigation/case management systems to promote CRC screening
in PY5?
partners
None. We did not partner with any organizations to implement patient navigation/case management systems to promote CRC
screening.
8a. Describe why partners were not used as part of your implementation of patient navigation systems.



10. Which of the following best describes the partner organization(s) you worked with to promote CRC screening using patient
navigator/case management systems in PY5?
(Check all that apply.)
Academic institution
Advocacy group/ Community-based organization/Community or health coalition
American Cancer Society
Another grantee
Chronic Disease programs within your agency
Comprehensive Cancer Control Coalition
Employers/worksites
Federally qualified health center (FQHC)
Indian Health Service (IHS) clinic or board, IHS Urban Indian health clinic
Individual health care provider/single practice
Local health department(s)
Medicare Quality Improvement Organization (QIO) office
Non-IHS tribal clinic, board, or health care facility
Private and/or non-profit health care system
Private health insurer
Professional organization (e.g., Primary care provider association in your state, state medical office)
Quality assurance organization
State Medicaid office
State office of rural health
Tribal council
Other (please specify)
Ease or Difficulty of Implementing Patient Navigation or Case Management Activities for CRC Screening Promotion
19. Thinking about the patient navigation or case management activities for CRC screening promotion that your organization
implemented in PY5, rate the level of ease or difficulty it took to implement them on average.
Very easy to
implement

Somewhat
easy

Neutral

Somewhat
difficult

Very difficult
to implement

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G. Other Interventions for CRC Screening Promotion
This section asks about your organization’s use of any other interventions to promote colorectal cancer screening to the wider population during
program year 5 (PY5). These other interventions may include those that have been evaluated as having insufficient evidence of effectiveness,
according to the Guide to Community Preventive Services.
1. Did your organization use any other interventions to promote colorectal cancer screening in PY5? These other interventions may include:
Provider education/professional development, including physician to physician education
1:1 education (other than patient navigation activities)
Group education
Mass media
Quality assurance (QA)/Quality improvement (QI), including academic detailing, performance monitoring
Client or provider incentives
“Your organization” refers to you, your contractors, and your partners.
Yes, we used other interventions to promote CRC screening in PY5.
No, we did not use other intervention to promote CRC screening in PY5, but have in the past (in any previous CRCCP contract year).
No, we have never used other interventions to promote CRC screening.
2. Which other interventions did your organization use for CRC screening promotion in PY5?
(Check all that apply.)
Provider education/professional development, including physician to physician education
1:1 education
Group education
Mass media
Quality assurance (QA)/Quality improvement (QI), including academic detailing, performance monitoring
Client or provider incentives
Other, please specify:
3.1.ia. Please describe your organization's previous attempts at using to promote CRC screening.



3.1.ib. Why did your organization stop using to promote CRC screening?



3.1.iii. Describe your activity for CRC screening promotion in PY5. Include details, such as the formal name (if any) of the effort, type of
QA effort, how it was implemented, etc.



3.1.iv. Describe any partnership involvement in your organization’s efforts or activities in PY5, e.g., what partners were involved, how
they were involved, how they came to be involved, etc.



3.1.v. For how long has your organization been using to promote colorectal cancer screening?
Less than 6 months
6-11 months
1-2 years
3-4 years
5 years or more
3.2.ia. Please describe your organization's previous attempts at using to promote CRC screening.



3.2.ib. Why did your organization stop using to promote CRC screening?




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3.2.iii. Describe your activity for CRC screening promotion in PY5. Include details, such as the formal name (if any) of the effort, type of
QA effort, how it was implemented, etc.



3.2.iv. Describe any partnership involvement in your organization’s efforts or activities in PY5, e.g., what partners were involved, how
they were involved, how they came to be involved, etc.



3.2.v. For how long has your organization been using to promote colorectal cancer screening?
Less than 6 months
6-11 months
1-2 years
3-4 years
5 years or more
3.3.ia. Please describe your organization's previous attempts at using to promote CRC screening.



3.3.ib. Why did your organization stop using to promote CRC screening?



3.3.iii. Describe your activity for CRC screening promotion in PY5. Include details, such as the formal name (if any) of the effort, type of
QA effort, how it was implemented, etc.



3.3.iv. Describe any partnership involvement in your organization’s efforts or activities in PY5, e.g., what partners were involved, how
they were involved, how they came to be involved, etc.



3.3.v. For how long has your organization been using to promote colorectal cancer screening?
Less than 6 months
6-11 months
1-2 years
3-4 years
5 years or more
3.4.ia. Please describe your organization's previous attempts at using to promote CRC screening.



3.4.ib. Why did your organization stop using to promote CRC screening?



3.4.iii. Describe your activity for CRC screening promotion in PY5. Include details, such as the formal name (if any) of the effort, type of
QA effort, how it was implemented, etc.



3.4.iv. Describe any partnership involvement in your organization’s efforts or activities in PY5, e.g., what partners were involved, how

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they were involved, how they came to be involved, etc.



3.4.v. For how long has your organization been using to promote colorectal cancer screening?
Less than 6 months
6-11 months
1-2 years
3-4 years
5 years or more
3.5.ia. Please describe your organization's previous attempts at using to promote CRC screening.



3.5.ib. Why did your organization stop using to promote CRC screening?



3.5.iii. Describe your activity for CRC screening promotion in PY5. Include details, such as the formal name (if any) of the effort, type of
QA effort, how it was implemented, etc.



3.5.iv. Describe any partnership involvement in your organization’s efforts or activities in PY5, e.g., what partners were involved, how
they were involved, how they came to be involved, etc.



3.5.v. For how long has your organization been using to promote colorectal cancer screening?
Less than 6 months
6-11 months
1-2 years
3-4 years
5 years or more
3.6.ia. Please describe your organization's previous attempts at using to promote CRC screening.



3.6.ib. Why did your organization stop using to promote CRC screening?



3.6.iii. Describe your activity for CRC screening promotion in PY5. Include details, such as the formal name (if any) of the effort, type of
QA effort, how it was implemented, etc.



3.6.iv. Describe any partnership involvement in your organization’s efforts or activities in PY5, e.g., what partners were involved, how
they were involved, how they came to be involved, etc.



3.6.v. For how long has your organization been using to promote colorectal cancer screening?
Less than 6 months

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6-11 months
1-2 years
3-4 years
5 years or more
3.7.ia. Please describe your organization's previous attempts at using to promote CRC screening.



3.7.ib. Why did your organization stop using to promote CRC screening?



3.7.iii. Describe your activity for CRC screening promotion in PY5. Include details, such as the formal name (if any) of the effort, type of
QA effort, how it was implemented, etc.



3.7.iv. Describe any partnership involvement in your organization’s efforts or activities in PY5, e.g., what partners were involved, how
they were involved, how they came to be involved, etc.



3.7.v. For how long has your organization been using to promote colorectal cancer screening?
Less than 6 months
6-11 months
1-2 years
3-4 years
5 years or more
H. Highlighting a successful evidence-based intervention (EBI) activity
We are interested in learning more about a successful EBI activity your organization has implemented for screening promotion Please tell us
about one EBI activity that you think has been the most effective or successful in your CRC screening promotion efforts.
1. Name of activity (as it’s referred to by your organization):

2. Please describe the main components of the EBI activity: what you did/do, how you did/do it, who was/is the target audience, and the
dates/duration of the activity.



3. Who was/is involved in your implementation efforts? (e.g. types of partners, their roll, etc.)



4. Did you adapt an existing intervention for this activity?
Yes
No
4a. What was the source for the original intervention?



4b. Why did you adapt the intervention? i.e. Why could you not use the intervention “as is?”




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4c. Describe the process for how you adapted it. (e.g. Were changes based on literature review, needs assessment, Community Advisory
Boards, focus groups, etc)



5. What do you think contributed to the success or effectiveness of this EBI?
Please include any details about methods, partners, or processes that you think were particularly innovative or important that contributed to
the success of your efforts.



6. What were the biggest challenges you encountered, if any, in implementing this EBI and how do you address them?



7. Is this EBI effort ongoing? If no, please tell us why not.



I. Other Comments – CRC Screening Promotion
1. Is there anything else you’d like us to know about your organization’s CRC Screening Promotion efforts?



SECTION 4: CANCER SCREENING DATA FROM FQHCs AND IHS CLINICS
These next questions are about health centers such as Federally Qualified Health Centers (FQHCs) and Indian Health Services (IHS) clinics that
you may have worked with in your state/tribal area during program year 5 (PY5).
1. Did any FQHCs clinics in your state report the following data to your ?
Yes

No

a. CRC screening rates
b. HEDIS data from insurers
c. CCDE or similar data for patients screened with resources other than CDC funds
d. Other CRC data, please describe:

1a. How many FQHCs reported CRC screening data to your organization?
PLEASE WRITE-IN THE NUMBER OR ENTER “Don't Know” (case sensitive).
FQHC(s) reported CRC screening data to my CRCCP
2. Are there any IHS clinics in your state/tribal area?
Yes
No
Don’t know
2a. Did any IHS clinics in your state/tribal area report the following data to your ?
Yes

No

a. CRC screening rates
b.
c. CCDE or similar data for patients screened with resources other than CDC funds
d. Other CRC data, please describe:

2b. How many IHS clinics reported CRC screening data to your CRCCP?
PLEASE WRITE-IN THE NUMBER OR ENTER “Don't Know” (case sensitive).
IHS clinic(s) reported CRC screening data to my CRCCP

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3. Did any health systems, insurers, or other clinic types (i.e. not including FQHCs, IHS or clinics that you are funding for screening provision)
in your state/tribal area report the following data to your ?
Yes

No

a. CRC screening rates
b. HEDIS data
c. CCDE or similar data for patients screened with resources other than CDC funds
d. Other CRC data, please describe:

3a. How many health systems, insurers, or other clinics (i.e. not including FQHCs or IHSs), report these CRC screening data to your CRCCP?
PLEASE WRITE-IN THE NUMBER OR ENTER “Don't Know” (case sensitive).
Reported CRC screening data to my CRCCP
SECTION 5: TRAINING AND TECHNICAL ASSISTANCE FOR EVIDENCE-BASED INTERVENTIONS

A. Program Training and Technical Assistance on Use of Evidence-Based Interventions
1. For which of the evidence-based strategies would you like to receive more training or technical assistance?
(Check all that apply.)
Small media (e.g., brochures, flyers)
Reducing structural barriers
Patient reminders
Provider reminders
Provider assessment and feedback systems
None
2. Do you have access to someone who can help you interpret and apply research evidence?
Yes
No
2a. Who is that person?

2b. With what type of organization is s/he affiliated?

3. How would you rate your desire for training in the following areas?
Desire for training
High

Medium

Low

Find evidence-based strategies or programs
Assess the strength of the evidence in support of a strategy or program’s effectiveness
Assess the fit of potential strategies or programs with my population
Assess the fit of potential strategies or programs with my organization’s systems, staff,
and resources
Assess organizational capacity to implement selected strategy
Adapt an evidence-based strategy or program to my population or setting
Implement a strategy/program with quality/fidelity
Conduct a process evaluation of an evidence-based strategy or program
Conduct an outcome evaluation of an evidence-based strategy
Insurance exchange "marketplace"/Medicaid expansion
ACA/Health reform and covered preventice services

B. Partner and Staff Training and Technical Assistance on Use of Evidence-Based Interventions.
1. Did you offer training on how to use any of the five Community Guide-recommended evidence-based interventions (EBIs) to increase
colorectal cancer screening to your partners, subcontractors, community health workers, patient navigators, or provider network in program
year 5 (PY5)?
Yes
No
Don’t know
1a. Please describe the training you offered on how to use any of the five Community Guide-recommended EBIs to increase CRC screening.
Please describe training content, target audience, etc.

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

2. Did you offer technical assistance (TA) on how to use any of the five Community Guide-recommended EBIs to increase colorectal cancer
screening to your partners, subcontractors, community health workers, patient navigators, or provider network in PY5?
Yes
No
Don’t know
2a. Please describe the technical assistance (TA) you offered on how to use any of the five Community Guide-recommended EBIs to increase
CRC screening. Please describe training content, target audience, etc.



3. For which activities do you/your staff most need technical assistance, training, or other support to enhance program implementation in the
coming year?
3a. Program Management – (Check up to 3.)
Developing program infrastructure
Staffing
Recruiting providers for screening provision
Contract management
Comprehensive program planning
Grant writing
Identifying funding
Managing budget funding
Communication
Integrating programs
Working with or managing contractors
Other, please specify
None. We do not desire any training in this area.
3b. Partnership Development – (Check up to 3.)
This area (partnership development) has not been addressed yet by our program.
Maintain a relationship with CDC-funded programs (e.g. CCC, NBCCEDP, WISEWOMAN)
Maintain a relationship with the Central Cancer Registry
Develop and maintain a partnership with your state/tribal organization’s CCC coalition
Develop and maintain partnerships with private and nonprofit health care systems
Develop and maintain partnerships with private health insurers
Develop and maintain a partnership with your state State Medicare and Medicaid office
Develop and maintain a partnership with FQHCs
Develop and maintain partnerships with professional organizations (e.g., state GI or primary care provider association)
Develop and maintain partnerships with other organizations. Please specify
Developing partnership agreements (e.g. MOU/MOA)
Evaluating partnerships
Severing ineffective partnerships
Other, please specify
None. We do not desire any training in this area.
3c. Screening Provision – (Check up to 3.)
Establish program infrastructure
Convene and maintain a Medical Advisory Board
Convene and maintain a Community Advisory Board
Recruit underinsured and uninsured individuals for CRC screening with CDC funds
Implement patient navigation and other support services
Provide or support the provision of screening and diagnostic services
Ensure appropriate treatment for complications and cancers
Support insurance enrollment
Develop and promote quality control standards and mechanisms among program-funded providers
Develop and promote clinical policies and procedures among program-funded providers
Develop, promote, or enhance training to educate health care professionals among program-funded providers
Address or resolve billing issues, e.g., determining Medicare rates/overbilling, dissatisfaction with rates
Other, (please specify)
None. We do not desire any training in this area.
3d. CRC Data Collection and Evaluation – (Check up to 3.)
Establish a patient data tracking system screening provision component
Collect and report patient data and monitor data quality through
Collect and report program activity cost data through the CAT
Develop an evaluation plan for your (e.g., formative, process, outcome, impact)
Conduct evaluation activities for your

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Identify and collect data from other sources (e.g., CRC screening rates from large health systems)
Collaborate with central cancer registry for data linkages and other purposes
Use data for program monitoring and program improvement
Implement strategies to document and communicate program value to stakeholders (e.g. legislators, funders, administrators)
Other (please specify)
None. We do not desire training in this area.
4. Are there any other resources or materials not previously covered in this section, that would be helpful to you as you implement any of
the five evidence-based strategies recommended by the Community Guide?
Yes
No
Not applicable: My organization is not currently using any Community Guide recommended strategies for CRC screening promotion
4a. Please describe the other resources or materials not previously covered in this section, that would be helpful to you as you implement
any of the five evidence-based strategies recommended by the Community Guide.



5. How satisfied are you with the technical assistance (TA) that CDC provided in PY5? Technical assistance refers to any assistance provided
directly to you by CDC staff; for example assistance provided by program consultants and team leads.
Not at all satisfied
Somewhat satisfied
Moderately satisfied
Very satisfied
Extremely satisfied
N/A - I have not received CDC TA about CRC control, to date
5a. Please describe how the TA can be improved



6. How satisfied are you with the training(s) that CDC provided or offered in PY5? Trainings may include but are not limited to webinars,
workshops at annual meetings, and workgroups.
Not at all satisfied
Somewhat satisfied
Moderately satisfied
Very satisfied
Extremely satisfied
N/A – I have not received CDC trainings about CRC control, to date
6a. Please describe how the training can be improved



7. What other CRCCP programs did you go to for advice or support to use the five Community Guide-recommended (evidence-based)
strategies?
(Check all that apply.)
Alabama
Arizona
California
Colorado
Connecticut
Delaware
Florida
Georgia
Iowa
Maine
Maryland
Massachusetts
Michigan
Minnesota
Montana
Nebraska
Nevada
New Hampshire
New Mexico
New York
Oregon
Pennsylvania

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South Dakota
Utah
Washington
Alaska Native Tribal Health Consortium
Arctic Slope Native Assoc.
South Puget Intertribal Planning Agency
Southcentral Foundation
None
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year

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Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)

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About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day

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7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
7a. How often were you given advice or received information from CRCCP program?
A couple of times a year
Less than once a month
Once or twice a month
Weekly (1 or more times/week)
About once a day
More than once a day
8. What other CRCCP programs did you collaborate with to implement any of the five Community Guide-recommended (evidence-based)
strategies?
(Check all that apply.)
Alabama
Alaska Native Tribal Health Consortium
Arctic Slope Native Assoc.
Arizona
California
Colorado
Connecticut
Delaware
Florida
Georgia
Iowa
Maine
Maryland
Massachusetts
Michigan
Minnesota
Montana
Nebraska
Nevada
New Hampshire
New Mexico
New York
Oregon
Pennsylvania
South Dakota
South Puget Intertribal Planning Agency
Southcentral Foundation
Utah
Washington
None
8a. What unfunded CRCCP programs did you collaborate with, if any, to implement any of the five Community Guide-recommended
strategies for CRC screening promotion?
(Check all that apply.)
Alaska
Arkansas
Cherokee Nation
Cheyenne River Sioux Tribe
District of Columbia
Hawaii
Hopi Tribe
Idaho
Illinois
Indiana
Kansas
Kaw Nation
Kentucky
Louisiana
Mississippi
Missouri
Native American Rehabilitation Association of the Northwest, Inc.
Navajo Nation
New Jersey
North Carolina
North Dakota
Ohio

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Oklahoma
Rhode Island
South Carolina
Southeast Alaska Regional Health Consortium
Tennessee
Texas
Vermont
Virginia
West Virginia
Wisconsin
Wyoming
Yukon-Kuskokwim Health Corporation
None
9. What non CDC-funded colorectal screening programs did you go to, or research, for advice or support to use the five Community Guiderecommended (evidence-based) strategies?



C. Comments – TA and Training
1. Do you have any other comments about training or technical assistance for evidence-based interventions?



SECTION 6: SCREENING POLICIES & STRATEGIES

A. Tobacco Screening Policies and Strategies
These next questions ask about policies and strategies to support tobacco screening and referral to quit lines for both CRCCP patients and nonCDC paid patients of CDC-funded program providers.
1. Does your program have a written policy in place that requires all contracted providers to both assess the smoking status of every person
screened by the CRCCP and refer those who smoke to their state tobacco quit line?
Yes
No
Don’t know
Not applicable – my organization does not provide direct-CRC screening services
1a. Has your program distributed this tobacco screening and referral policy to all providers funded through the program to screen men
and women for CRCCP?
Yes, all providers
Yes, some providers
No
Don’t know
B. Strategies to Support CRC Screening
1. In program year 5 (PY5), did you execute two or more formal agreements (e.g., MOU, MOA, contract) with a health care system, health
insurer, or large workplace to facilitate and support CRC screening?
The agreement may include things such as:
1) Data reporting
2) A formal CRC quality improvement effort
3) An organizational policy or benefits package to cover screening
4) An uncompensated screening commitment; and/or
5) Implementation of Community Guide evidenced-based interventions
Yes
No
Please tell us how many formal agreements (MOU, MOA, or contract), you executed with each entity below to facilitate and support CRC
screening:
1a.
Health care system:
Please provide health care system name(s). Write-in 'NA' if you entered zero above.



1b.
Health insurer:

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Please provide health insurer name(s). Write-in 'NA' if you entered zero above.



1c.
Workplace:
Please provide workplace name(s). Write-in 'NA' if you entered zero above.



2. In program year 5 (PY5), were there any new or revised organizational policies (e.g., insurer reduces co-pay for CRC screening, workplace
provides time off for colonoscopy) and systems changes in any of your partner organizations (e.g., workplaces, Insurers, health systems)
that affect colorectal cancer control?
Yes
No
2.a. How many new or revised organizational policies have there been in PY5 that affect colorectal cancer control?
1
2
3
4 or more
2b. Of these new or revised policies that affect colorectal cancer control, please tell us about the policy that you view to be the most
successful, or that has the potential for most impact:
2b.i. State the name of the organization

2b.ii. Indicate the type of organization
Large employer/worksite
Private/nonprofit health care system
FQHCs
Private health insurers
Other
2b.iii. Indicate the scope of the organization
State/tribal organization-wide
County-wide
City-wide
Other
2b.iv. Describe the policy’s major requirements or mandates



2b.v. Describe your CRCCP program’s role in supporting its development and/or adoption



SECTION 7: GENERAL PROGRAM MANAGEMENT

A. Monitoring and Evaluation
1. What level of ease or difficulty did you experienced for each of the following monitoring and evaluation issues for your CRC activities in the
past year?
Very Easy

Somewhat
Easy

Neutral

Somewhat
Difficult

Very
Difficult

Not
Applicable

a. Collecting clinical data for persons screened through our CRC
screening provision efforts
b. Conducting program evaluation
c. Acquiring BRFSS data
d. Using BRFSS data for program planning or evaluation

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e. Acquiring claims or HEDIS data
f. Using claims or HEDIS data for program planning or
evaluation
g. Acquiring CRC screening rate data from clinics, health
systems, or insurers
h. Using CRC screening data for program planning or evaluation
i. Gathering new data (e.g., from providers or specific
communities)
j. Analyzing/interpreting new data
k. Acquiring Medicare/Medicaid data
l. Acquiring RPMS data

2. Did you conduct any evaluation of your CRC screening promotion or provision activities in program year 5 (PY5)? This could include
formative, process, outcome, or impact evaluations (e.g., referrals, screening numbers) of your activities?
Examples of evaluation types and activities:
Formative – what messages or activities people would like to know/have about CRC
Process – information about how program activities were implemented
Impact – knowledge, attitudes, screening behaviors
Outcome – screening rates at state level
Yes
No
2.a. If yes, tell us what type of activity was evaluated.

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2.b. How did you conduct the evaluation?

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B. Administrative Challenges
1. What level of ease or difficulty did you experience for each of the following administrative issues related to CRC control activities in PY5?
Very Easy

Somewhat
Easy

Neutral

Somewhat
Difficult

Very Difficult

Not
Applicable

a. Spending CDC funding
b. Hiring staff for CRC efforts
c. Training staff for CRC efforts
d. Retaining staff for CRC efforts
e. Establishing contracts with other partners
f. Establishing MOAs/MOUs with partners
g. Securing funding from sources other than
CDC to support promoting or providing CRC
screening
h. Having sufficient funding across funding
sources (CDC + other) to support CRCCP
program goals
i. Gaining approvals for traveling to CDC or
other professional development opportunities
j. Political issues within the state/tribe
k. Immigrant/legal residency issues
l. Securing furloughs

1.e.i. Describe why establishing contracts with partners was challenging. For example, was the contracting process too burdensome, do
partners not want to contract with your state/tribe, etc.

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1.f.i. Describe why establishing MOA/MOU with partners was challenging. For example, was the MOA/MOU process too burdensome, do
partners not want to formalize an agreement with your state/tribe, etc.

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C. Final Comments
1. What was the biggest CRC control challenge you faced in this last contract year (PY5; 7/1/13-6/30/14) and how did you overcome it?

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2. What has been your greatest CRC control success in this last contract year (PY5; 7/1/13-6/30/14) and how have you promoted it?

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CLOSING QUESTIONS
1. Did you consult with anyone (e.g. colleagues, partners, subcontractors, etc) to answer any of the survey questions?
Yes
No
1a. Tell us with whom you consulted to complete this survey.
(Check all that apply.)
CRCCP Program Director
CRCCP Program Manager/Coordinator
CRCCP Data Manager
CRCCP-participating clinics
CDC CRCCP Program Staff
CRCCP Administrator
NBCCEDP Staff
NBCCEDP Program Director
NBCCEDP Program Manager/Coordinator
CCC co-chairs
Insurer
Partner
Other 1, please specify
Other 2, please specify
Other 3, please specify
END SURVEY
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