Clinic Staff Survey - PHC Evaluation - Att 10

Attachment 10

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Positive Health Check Evaluation

Aim 2: Implementation Analysis

Instrument: Clinic Staff Survey

Public reporting burden of this collection of information is estimated to average 15 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)

Data Collection Details:

• Participant(s): The exact persons completing the survey will be determined with the project coordinator based on who will provide the best information. This could include some PHC staff and other clinic staff affected by the implementation.

• Frequency of Data Collection: Every 3 months

• Participant Time Required: 15 minutes

Thank you for taking this online survey. Please note that when completing this survey, ‘PHC project staff implementing PHC’ refers to staff involved in the project whether they are involved day to day (such as the coordinator, data manager or outreach coordinator) or periodically (such as the clinic champion). Additionally, when asked about ‘clinic staff’, please consider all those employed by the clinic such as health care providers and administrative support staff.