Form 0920-1030 Telephone Script

Attachment B - NSHVS Telephone Questionnaire Script

Form Approved

OMB No. 0920-1030

Exp. Date 04/30/2020

US Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics (NCHS) & US Department of Justice Bureau of Justice Statistics (BJS)	Frame Development of Hospital-based Victim Services
Notice - CDC estimates the average public reporting burden for this collection of information as 15 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1030). Assurance of confidentiality –Data collection for this project is authorized by Section 306 of the Public Health Service Act for NCHS and 34 U.S.C. § 10232 for BJS. The information you provide will be used for research purposes only and will be held in strict confidence in accordance with Section 308(d) of the Public Health Service Act [42 U.S. Code 242m(d)] for NCHS and 34 § 10231 for BJS and data will be safeguarded according to federal mandates requiring data security procedures such as data encryption and secure data networks.
CALL TO THE RESPONDENT Hello, my name is [NAME]. I’m calling on behalf of the National Center for Health Statistics about a joint project with the Bureau of Justice Statistics. We are trying to reach someone who can provide us with information about programs or services the hospital has for people who have been victims of crime or abuse, for example domestic violence, sexual assault, human trafficking, or other intentional injuries. Do you have about 15 minutes to talk to me about the services available in your hospital? Your participation is completely voluntary. [OPTION 1]: If available at the moment → THEN, PROCEED WITH THE TELEPHONE VERSION OF THE SURVEY AND BEGIN SURVEY OVER THE PHONE. [*See below for the draft of telephone survey] [OPTION 2]: If not available at the moment but willing to complete the survey → THEN, PROCEED WITH SCHEDULING THE CALL. [OPTION 3]: If NOT the best person to talk to about these services: Who is the best person to talk to about victim services available at your hospital? [COLLECT THE PERSONS NAME AND INFORMATION]

*TELEPHONE SURVEY VERSION

Thank you for taking the time to speak with me today. As I mentioned, we are calling to gather basic information about any programs or services you have available to victims of crime or abuse. Your participation is completely voluntary. If at any point you think there is someone else we should talk to, in addition to you, please let me know.

[INTERVIEWER – read out loud to respondent]:

NCHS and BJS are developing a sampling frame of hospitals offering these programs and services which can be used by BJS to conduct future surveys about hospitals offering victim services. Therefore, it is possible that you may be recontacted in the future. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for the purposes of a frame development. Data collection for this project is authorized by Section 306 of the Public Health Service Act for NCHS and 34 U.S.C. § 10232 for BJS. The information you provide will be used for research purposes only and will be held in strict confidence in accordance with Section 308(d) of the Public Health Service Act [42 U.S. Code 242m(d)] for NCHS and 34 § 10231 for BJS and data will be safeguarded according to federal mandates requiring data security procedures such as data encryption and secure data networks.

[INTERVIEWER – If any additional information about the pledge is requested by the respondent, then the NCHS confidentiality brochure will be offered to be sent via email or mail after permission is given by respondent.]

First, a bit of background on the project: When victims go to a hospital for injuries, this is often the first time victims seek assistance in a formal setting. Yet we know little about the services that are available for victims of crime or abuse in hospitals, other than medical care to treat their presenting injuries.

Do you have any questions? [Answer questions, then proceed with survey.]

[INTERVIEWER – proceed to the CATI]

Great! First, let me confirm that we have the correct information for you [confirm information is correct, correct or fill in missing information if necessary]:

Position Title:

Name:

Contact info:

Next I have a few questions about the hospital:

How many staffed inpatient beds are currently in your hospital?

 less than 6 beds

 6-49 beds

 50-99 beds

 100-199 beds

 200-299 beds

 300-499 beds

 500-999 beds

 1000 or more beds

Which of the following best describes your hospital?

 General Acute

 Children

 Psychiatric

 Other (Specify): __________________

Does your hospital have an emergency department?

 Yes → Proceed to the question below

 No

If yes, does it operate 24 hours a day?

 Yes

 No

Now I’d like to gather information on all the programs or services you have available for victims of crime or abuse–this includes any person who experienced reckless or intentional injury or harm, such as victims of sexual assault, domestic violence, human trafficking, community violence, assault, child abuse and neglect, elderly abuse, etc.

Question 1. Does your hospital have any programs or services that are available to patients or their family specifically because they are victims of crime or abuse? Include all types of victim programs and services in your hospital, even if run by contract staff, pro-bono staff, or volunteers. For example, consider:

• Programs, centers, clinics, unit, divisions, or institutes dedicated to providing services to victims of crime or abuse, such as Domestic Violence and/or Sexual Assault programs or clinics, Violence Intervention Programs, Child Advocacy Centers, Family Violence Unit, Rape Crisis Centers, Legal Aid Programs, Human Trafficking Intervention Programs, Victim Houses, among others;

Also consider:

• Staff teams or Individual Staff including crisis intervention staff, social worker dedicated to providing services to victims, group counselor or mental health specialist, victim compensation specialists, Sexual Assault Examiner Nurses (SANE), or other professionals in your hospital who focus on providing services to victims of crime or abuse.

• Yes → Proceed to item 1a. [Interviewer: gather the contact information for each type of service available in the hospital ]

• No → Skip to item 2

1a. If yes, please provide the name for each of the services or programs along with contact information for how best to reach them:

	Contact information:	Crime types for which services are provided (check all that apply):
1)	Name [of program, service, staff, etc.]: Point of contact: Email: Mailing address: Phone number: Position title for point of contact:	__ All crime types __Domestic violence/intimate partner violence/dating violence __Rape or sexual assault __Human trafficking (sex or labor) __Child abuse or maltreatment __Community violence (including gang violence, peer violence, and gun violence) __ Homicide (including support groups for surviving family) __Elder abuse __Other, specify: _____________________
	Contact information:	Crime types for which services are provided (check all that apply):
2)	Program/entity name: Point of contact: Email: Mailing address: Phone number: Position title for point of contact:	__ All crime types __Domestic violence/intimate partner violence/dating violence __Rape or sexual assault __Human trafficking (sex or labor) __Child abuse or maltreatment __Community violence (including gang violence, peer violence, and gun violence) __ Homicide (including support groups for surviving family) __Elder abuse __Other, specify: ____________________
	Contact information:	Crime types for which services are provided (check all that apply):
3)	Program/entity name: Point of contact: Email: Mailing address: Phone number: Position title for point of contact:	__ All crime types __Domestic violence/intimate partner violence/dating violence __Rape or sexual assault __Human trafficking (sex or labor) __Child abuse or maltreatment __Community violence (including gang violence, peer violence, and gun violence) __ Homicide (including support groups for surviving family) __Elder abuse __Other, specify: _____________________
	Contact information:	Crime types for which services are provided (check all that apply):
4)	Program/entity name: Point of contact: Email: Mailing address: Phone number: Position title for point of contact:	__ All crime types __Domestic violence/intimate partner violence/dating violence __Rape or sexual assault __Human trafficking (sex or labor) __Child abuse or maltreatment __Community violence (including gang violence, peer violence, and gun violence) __ Homicide (including support groups for surviving family) __Elder abuse __Other, specify: _____________________

Partnerships

[If listed programs, entities, or staff above:] We recognize inter-agency collaborations are often an important part of these programs services for victims, so we’d like to know if your hospital provides services to victims through any additional inter-agency partnerships that are independent from the programs and staff listed above.

Question 2. Does your hospital work with other agencies through partnerships, taskforces, or teams to provide services to victims of crime or abuse? Please do not list partnerships that are part of the programs listed above. Examples include inter-agency violence intervention teams, human trafficking taskforces, and partnerships with police, other hospitals, or community-based agencies to connect victims to services, etc.

• Yes → Proceed to item 2a.

• No →Skip to item 3

2a. If yes, please provide the following information for each:

	Inter-agency partnership, taskforce, or team:	Crime types for which the partnership serves:
1)	Partnership, taskforce, or team name: Point of contact: Email: Mailing address: Phone number: Position title for point of contact:	__ All crime types __Domestic violence/intimate partner violence/dating violence __Rape or sexual assault __Human trafficking (sex or labor) __Child abuse or maltreatment __Community violence (including gang violence, peer violence, and gun violence) __Homicide __Elder abuse __Other, specify: _____________________
	Inter-agency partnership, taskforce, or team:	Crime types for which the partnership serves:
2)	Partnership, taskforce, or team name: Point of contact: Email: Mailing address: Phone number: Position title for point of contact:	__ All crime types __Domestic violence/intimate partner violence/dating violence __Rape or sexual assault __Human trafficking (sex or labor) __Child abuse or maltreatment __Community violence (including gang violence, peer violence, and gun violence) __Homicide __Elder abuse __Other, specify: _____________________

Question 3. Does your hospital offer any other programming or services for victims of crime or abuse that were not described previously?

• Yes →Proceed to item 3a.

• No →Skip to item 4

3a. If yes, please provide the following information for each of them:

Contact information:	Crime types for which services are provided (check all that apply):
Name [of program, service, staff, etc.]: Point of contact: Email: Mailing address: Phone number: Position title for point of contact:	__ All crime types __Domestic violence/intimate partner violence/dating violence __Rape or sexual assault __Human trafficking (sex or labor) __Child abuse or maltreatment __Community violence (including gang violence, peer violence, and gun violence) __ Homicide (including support groups for surviving family) __Elder abuse __Other, specify: _____________________

Plans for new victim services

Question 4. In the next year, is your hospital planning to create any new programs or entities, hire new staff, or participate in any new inter-agency partnerships, taskforces, or teams designated to serve victims of crime or abuse?

• Yes → Proceed to item 4a.

• No →Skip to item 5

• Do not know →Skip to item 5

4a. If yes, specify: _______________________________________________________________

Record Keeping

Question 5. When providing victim services, does your hospital use any type of electronic system that maintains and/or tracks individual victim cases?

• Yes → Proceed to item 5a.

• No → [Interviewer: and this concludes the interview. Thank you very much for your time.]

• Do not know [Interviewer: and this concludes the interview. Thank you very much for your time.]

5a. If yes, specify: _______________________________________________________________

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