Att. 3e_ Partner Survey & Partner Survey Screener

Form Approved

OMB No: 0920-New

Exp. Date: XX/XX/XXXX

Evaluation of Enhancing HIV Prevention Communication and

Mobilization Efforts through Strategic Partnerships

Attachment 3e:

Partner Survey

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

Thanks for your willingness to complete this survey.

Section A: Organizational Policies

A.1	This group of questions asks about the worksite policies of your organization, [IF YOU THINK THAT SOMEONE ELSE WOULD BE BETTER ABLE TO ANSWER THEM, PLEASE INDICATE HERE] I CAN ANSWER THE QUESTIONS [Continue to A.2] SOMEONE ELSE IS BETTER ABLETO ANSWER THESE QUESTIONS [Skip to SECTION B]
A.2	Does your organization screen employees for any of the following?
A.2.a	Illegal drug use? YES NO Prefer not to answer
A.2.b	Infectious disease? YES [Continue to A.2.c] NO [Skip to A.3] Prefer not to answer [Skip to A.3]
A.2.c	Which ones? (VIRAL) HEPATITIS (B, C) TUBERCULOSIS OR TB HIV MEASLES MUMPS RUBELLA CHICKEN POX OTHER [SPECIFY]: Prefer not to answer
A.3	To your knowledge, has your organization ever had an employee with HIV/AIDS? YES [Continue to A.3.a] NO [Skip to A.5] Prefer not to answer [Skip to A.5]
A.3.a	How did this come to the attention of your organization? EMPLOYEE DISCLOSURE DEATH OF EMPLOYEE INFORMATION FROM INSURANCE CLAIMS OTHER [SPECIFY]:________________________ Prefer not to answer
A.4	Has your organization knowingly hired a person with HIV/AIDS? YES NO Prefer not to answer
The following questions ask about policies that influence the workplace environment. By policies, we mean written and unwritten philosophies, guidelines, or rules that are known to managers and employees.
A.5	Does your organization have a policy that addresses issues regarding an employee with a disability or life­ threatening illness? YES [Continue to A.6] NO [Skip to A.7] Prefer not to answer [Skip to A.7]
A.6	Is there any policy that exclusively addresses employees with HIV/AIDS? YES [Continue to A.6.a] NO [Skip to A.7] Prefer not to answer
A.6.a	Is this a written policy? YES NO Prefer not to answer
A.6.b	Is this a organization-wide policy or just for this specific worksite? COMPANY-WIDE/ORGANIZATION-WIDE JUST THIS WORKSITE Prefer not to answer
A.6.c	Which of the following issues does this policy address? (Please check all that apply.) Hiring employees with HIV/AIDS Performance standards for employees with HIV/AIDS Defining ways management will respond to an HIV positive employee Providing reasonable accommodation for employees with HIV/AIDS Defining ways in which management will address discrimination against an employee with HIV/AIDS Social support programs available to employees and their family members with HIV/AIDS Dismissing employees with HIV/AIDS Employee education about the transmission of HIV/AIDS Prefer not to answer
A.6.d	When was this HIV/AIDS policy first implemented? _____________________ Prefer not to answer
A.6.e	Does your organization educate its employees about HIV/AIDS policies? YES [Continue to A.6.f] NO [Skip to A.7] Prefer not to answer
A.6.f	How does your company/organization do this? (Please check all that apply.) TRAINING PROGRAMS STAFF MEETINGS NEW EMPLOYEE ORIENTATION WRITTEN DISTRIBUTION OF THE POLICY OR POLICIES OTHER [SPECIFY]: _________________________________ Prefer not to answer
A.6.g	Does your organization have a training program exclusively for managers and supervisors that educated them about these HIV/AIDS policies? YES [Skip to A.8] NO [Skip to A.8] Prefer not to answer [Skip to A.8]
A.7	Are you aware of any plans to develop a policy that exclusively addresses HIV/AIDS? YES [Continue to A.7.a] NO [Skip to A.8] Prefer not to answer
A.7.a	What information materials, or support would your organization need in order to implement an HIV/AIDS policy? (Please check all that apply.) Sample policy language Estimated cost associated with implementing a policy Technical assistance by phone or email Nothing, we can do it ourselves OTHER [SPECIFY]:_____________________________________________ Prefer not to answer
A.8	Does your organization have any policy that defines ways in which management will address workplace discrimination? YES [Continue to A.8.a] NO [Skip to A.9] Prefer not to answer
A.8.a	Does your /organization educate its employees about these policies? YES [Continue to A.8.b] No [Skip to A.9] Prefer not to answer
A.8.b	How does your organization do this? (Please check all that apply.) TRAINING PROGRAMS STAFF MEETINGS NEW EMPLOYEE ORIENTATION WRITTEN DISTRIBUTION OF THE POLICY OR POLICIES OTHER. [SPECIFY]: ________________________________ Prefer not to answer
A.9	Does your organization have any policy regarding the provision of reasonable accommodation for employees with disabilities or life-threatening illnesses? YES [Continue to A.9.a] NO [Skip to A.10] Prefer not to answer
A.9.a	Does your organization educate its employees about these policies? YES [Continue to A.9.b] No [Skip to A.10] Prefer not to answer
A.9.b	How does your organization do this? (Please check all that apply.) TRAINING PROGRAMS STAFF MEETINGS NEW EMPLOYEE ORIENTATION WRITTEN DISTRIBUTION OF THE POLICY OR POLICIES OTHER. [SPECIFY]: ________________________________ Prefer not to answer
A.10	What information, materials or support would your organization need in order to implement a workplace education program about HIV/AIDS? (Please check all that apply.) Estimated cost associated with implementing a program The names of people to lead training sessions Materials that we can supply to the employees Technical Assistance by phone or email Nothing, we can do it ourselves OTHER. [SPECIFY]:_____________________________________________ Prefer not to answer
A.11	What would your organization need in order to implement a philanthropic or volunteer program about HIV/AIDS? (Please check all that apply.) Estimated cost associated with implementing a program Ideas for what we could do as a company/organization Ideas for what individuals could do on a voluntary basis Technical Assistance by phone or email Nothing, we can do it ourselves OTHER. [SPECIFY]:_____________________________________________ Prefer not to answer

Section B: Policies/Procedures Regarding Health and Safety

B.1	Now you will be asked some general questions about the policies regarding health and safety. [IF YOU THINK THAT SOMEONE ELSE WOULD BE BETTER ABLE TO ANSWER THEM, PLEASE INDICATE HERE.] I CAN ANSWER THE QUESTIONS [Continue to B.2] SOMEONE ELSE IS BETTER ABLE TO ANSWER THESE QUESTIONS [Continue to SECTION C]
B.2	Are any of your employees at this worksite exposed to human blood or other bodily fluids as part of their jobs? YES [Continue to B.2.a] NO [Skip to B.5] Prefer not to answer [Skip to B.5]
B.2.a	What tasks are these employees performing that potentially result in exposure? (Please check all that apply.) CONSTRUCTION/CARPENTRY WORK EMERGENCY MEDICAL RESPONSE, POLICE OR FIRE WORK FIRST AID HEALTH CARE HOME CARE JANITORIAL, MAINTENANCE, OR HOUSECLEANING WORK MACHINERY OPERATION MEAT OR POULTRY, FOOD PREPARATION OTHER [SPECIFY]:_______________________________________ Prefer not to answer
B.2.b	What are their occupations? (Please check all that apply.) CONSTRUCTION/CARPENTRY WORK EMTs, FIRST RESPONDERS, PUBLIC SAFETY OFFICERS, ETC. JANITORIAL, MAINTENANCE, OR HOUSECLEANING STAFF HEALTH CARE WORKERS (NURSES, MDs, ALLIED HEALTHWORKERS) HOME CARE WORKERS (HOME HEALTH AIDES, ETC.) MACHCNERY OPERATIONS MEAT OR POULTRY, FOOD PREPARERS SAFETY MANAGERS/OTHERS RESPONSIBLE FOR PROVIDING FIRST AID OTHER [SPECIFY]: _______________________________________ Prefer not to answer
B.3	Does your organization have policies in place regarding prevention of exposure to human blood or other bodily fluids in this worksite? YES NO Prefer not to answer
B.4	Does your organization have a policy or exposure control plan for blood-borne pathogens? YES NO Prefer not to answer
B.5	How much do you think senior management in your organization has promoted HIV awareness & prevention? To a Great Extent Somewhat Very Little Not at All Prefer not to answer

Section C: Employee and Family Education

C.1	The next group of questions asks about education programs that your company/organization provided for either some or all of its employees. [IF YOU THINK THAT SOMEONE ELSE WOULD BE BETTER ABLE TO ANSWER THEM, PLEASE INDICATE HERE] I CAN ANSWER THE QUESTIONS [Continue to C.2] SOMEONE ELSE IS BETTER ABLE TO ANSWER THESE QUESTIONS [Skip to SECTION D]
C.2	During the past 12 months, did your organization offer any general educational programs or activities that addressed HIV/AIDS? YES [Continue to C.3] NO [Skip to SECTION D] Prefer not to answer [Skip to SECTION D]
C.3	Was this program designed to educate employees about occupational risks of HIV, about AIDS in general or both? ABOUT OCCUPATIONAL RISKS OF HIV ABOUT AIDS IN GENERAL BOTH Prefer not to answer
C.4	Were the HIV/AIDS activities exclusively devoted to HIV/AIDS or were HIV-related issues presented with other issues? EXCLUSIVELY DEVOTED TO HIV/AIDS [Skip to C.5] PRESENTED WITH OTHER ISSUES [Continue to C.4.a] Prefer not to answer [Skip to C.4.a]
C.4.a	What were the other issues? ____________________________________________  Prefer not to answer
C.5	Was the program based on a standardized curriculum? By that, we mean a planned session with learning objectives. YES NO Prefer not to answer
C.5.a	Did the HIV/AIDS program consist of any of the following? (Please check all that apply.) Health fair [Skip to C.6] Videos [Skip to C.6] Literature/brochures [Continue to C.5.b] Posters [Skip to C.6] Internet/Website [LIST]: __________________________________ [Skip to C.6] OTHER [SPECIFY]: _____________________________________ [Skip to C.6] Prefer not to answer [Skip to C.6]
[IF THE RESPONDENT'S ANSWER/S IS/INCLUDES "LITERATURE/BROCHURES", ASK C.5.b. ELSE GO TO C.6]
C.5.b	How were these materials available to employees? (Please check all that apply.) Distributed through the company/organization mail Available at a central location on the worksite Available only by request During an educational program OTHER [SPECIFY]: ________________________________________ Prefer not to answer
C.6	Was the program mandatory for managers and supervisors? YES NO Prefer not to answer
C.7	Was the program mandatory for employees other than managers and supervisors? YES NO Prefer not to answer
C.8	Did employees attend this program on organization time? By "organization time," we mean "time during which your organization is paying employees." YES NO Prefer not to answer
C.9	How often is this program offered? LESS THAN ONCE A YEAR ONE TIME PER YEAR TWO TIMES PER YEAR 3 TO 5 TIMES PER YEAR 6 TO 11 TIMES PER YEAR 12 OR MORE TIMES PER YEAR Prefer not to answer
C.10	Did family members also participate in this educational session? YES NO Prefer not to answer
C.11	We'd like to hear more about the educational session. Which of the following did the educational program address? (Please check all that apply.) Transmission of HIV Symptoms of HIV/AIDS Treatment of HIV infection and AIDS' A speaker with HIV/AIDS Personal behaviors to protect oneself from HIV/AIDS Work-related behaviors protect oneself from HIV/AIDS How to respond to a co-worker with HIV/AIDS How to talk with your family about HIV/AIDS Company/Organization policies about HIV/AIDS Where to go for help if you have HIV/AIDS Information about sexually-transmitted diseases other than HIV/AIDS Prefer not to answer
C.12	When was this program first implemented? ______________________________________  Prefer not to answer
C.13	Has your organization ever provided educational programs for employees’ families that addressed HIV/AIDS in some way? YES [Continue to C.13.a] NO [Skip to SECTION D] Prefer not to answer [Skip to SECTION D]
C.13.a	Was this program similar in any way to the one that was offered to employees? YES [Continue to C.13.b] NO [Skip to C.13.c] Prefer not to answer [Skip to C.13.c]
C.13.b	How was it similar? _________________________________ Prefer not to answer
C.13.c	How was it different? _________________________________ Prefer not to answer

Section D: Philanthropic or Charitable Activities

D.1	This last group of general questions asks about your organization’s philanthropic or charitable activities. [IF YOU THINK THAT SOMEONE ELSE WOULD BE BETTER ABLE TO ANSWER THEM, PLEASE INDICATE HERE.] I CAN ANSWER THE QUESTIONS [Continue to D.2] SOMEONE ELSE IS BETTER ABLE TO ANSWER THESE QUESTIONS [Skip to SECTION E]
D.2	Has your organization ever organized or participated in a fundraising activity for health-related causes? YES [Continue to D.2.a] NO [Skip to D.4] Prefer not to answer [Skip to D.4]
D.2.a	Has your organization ever organized or participated in a fundraising activity for causes that include HIV/ AIDS? YES NO Prefer not to answer
D.3	Has your organization ever organized or participated in a fundraising activity specifically for HIV/ AIDS? YES NO Prefer not to answer
D.4	Has your organization ever provided corporate grants or financial donations to organizations that address HIV/AIDS? YES NO Prefer not to answer
D.5	Has your organization ever offered the use of its facilities or equipment for activities or meetings that addressed HIV/AIDS? YES NO Prefer not to answer
D.6	Has your organization ever loaned staff for activities or to organizations that addressed HIV/AIDS? YES NO Prefer not to answer
D.7	Has your organization ever participated in or supported educational programs offered by local schools or other community organizations? YES NO Prefer not to answer

Section E: Awareness of CDC’s HIV Communication Initiatives

[ASK ALL RESPONDENTS]

E.1	Where would you expect to seek information and expertise relating to HIV prevention? (Please check all that apply.) Health Department Family Physician Health Insurance Company Centers for Disease Control and Prevention (CDC) Internet/Website [SPECIFY]: _____________________________________________ Hospital/Clinic OTHER [SPECIFY]:___________________________________________________ Prefer not to answer
E.2	Have you ever heard of CDC's Business Responds to AIDS (BRTA) Program? YES [Continue to E.2.a] NO [Skip to E.3] Prefer not to answer [Skip to E.3]
E.2.a	How would you rate your knowledge of the BRTA program? High Medium Low Prefer not to answer
E.2.b	How did you hear about the BRTA program? (Please check all that apply.) AIRPORT DISPLAY ANOTHER COMPANY CDC WEBSITE SOCIAL MEDIA [PLEASE LIST (Twitter, Facebook, Blog): _________________________ LITERATURE IN THE MAIL MAGAZINE ADVERTISEMENT/ ARTICLE NEWSPAPER ADVERTISEMENT/ARTICLE REGIONAL BRTA BRIEFING OR CONFERENCE TELEVISION NEWS/TALK SHOWS TRADE SHOW OR PROFESSIONAL CONFERENCE [SPECIFY]: ___________________ UNION OTHER [SPECIFY]: ______________________________ Prefer not to answer
E.2.c	Is your organization a BRTA partner? By that, we mean has your organization signed up to participate in the BRTA program? YES NO Prefer not to answer
E.2.d	Have you ever used any materials/resources from the BRTA program? YES [Continue to E.2.e] NO [Skip to E.3] Prefer not to answer [Skip to E.3]
E.2.e	What resources did you use? _________________________________ Prefer not to answer
E.2.f	How did you use them? _________________________________ Prefer not to answer
E.3	Have you ever heard of CDC's Act Against AIDS (AAA) Initiative? YES [Continue to E.3.a] NO [Skip to E.4] Prefer not to answer [Skip to E.4]
E.3.a	How did you hear about the AAA Initiative? (Please check all that apply.) AIRPORT DISPLAY ANOTHER COMPANY CDC WEBSITE SOCIAL MEDIA [PLEASE LIST (Twitter, Facebook, Blog): ____________________________________ LITERATURE IN THE MAIL MAGAZINE ADVERTISEMENT/ ARTICLE NEWSPAPER ADVERTISEMENT/ARTICLE REGIONAL BRTA BRIEFING OR CONFERENCE TELEVISION NEWS/TALK SHOWS TRADE SHOW OR PROFESSIONAL CONFERENCE [SPECIFY]: ______________________________ UNION OTHER [SPECIFY]: ______________________________ Prefer not to answer

[IF A.1 OR B. l OR C.1 OR D.1 = "SOMEONE ELSE IS BETTER ABLE TO ANSWER THESE QUESTIONS, GO TO E4; ELSE GO TO CONCLUDING STATEMENT)

E.4

Could you suggest someone who would be able to answer questions about your organization’s information?

YES ----------->	Name: _______________________ Title: _______________________ Dept: _______________________ TEL: _______________________
NO

Concluding Statement

Thank you very much for your time. We really appreciate our willingness to answer our questions. You've been very helpful.

11