Safe to Sleep NICHD Generic instruments

OMB # 0925-0701
Expiration Date: 07/31/2017

Safe Sleep Outreach
Project Assessment Form
Public reporting burden for this collection of information is estimated to average 3 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda,
MD 20892-7974, ATTN: PRA (0925-0701). Do not return the completed form to this address.

Please fully complete this form, and return it to your presenter. Your feedback is very
important. Thank you. Do NOT write your name on this form.
Host organization:
Event Date:
Activity type:

BEFORE This Program

Strongly
Disagree Disagree Neutral

Agree

Strongly
Agree

1) In my home, the place where baby
sleeps has soft bedding (example:
pillows, blankets, toys, bumpers, or
other soft items).

1

2

3

4

5

2) I know that the safest place for baby
to sleep is in the same room as the
caregiver but in his or her own crib or
bassinet.

1

2

3

4

5

3) Putting baby on his or her back to
sleep is important to reduce the risk of
SIDS.

1

2

3

4

5

Please complete the sections below AFTER the program
AFTER This Program
1) In my home, the place where baby
sleeps has soft bedding (example:
pillows, blankets, toys, bumpers, or
other soft items).
2) I know that the safest place for baby
to sleep is in the same room as the
caregiver but in his or her own crib or
bassinet.
3) Putting baby on his or her back to
sleep is important to reduce the risk of
SIDS.
Program Assessment
1) Presenter demonstrated expert
knowledge on safe sleep.
2) After completing this program, I
know ways to reduce the risk of SIDS
and other sleep-related causes of
infant death.
3) This program taught me safe infant
sleep habits that I can use in my home
with my family.
4) I would share this information with
friends, family, and other caregivers
who take care of babies.

I would like more information about:

Strongly
Disagree

Disagree Neutral

Agree

Strongly
Agree

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Agree

Strongly
Agree

Strongly
Disagree

Disagree Neutral

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

OMB # 0925-0701
Expiration Date: 07/31/2017

Alabama Safe Sleep Outreach Project
Activity Tracking Form
Public reporting burden for this collection of information is estimated to average up to 30 minutes, 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: NIH,
Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0701). Do not
return the completed form to this address.

Organization:
Date of Report:

(Month/Day/Year)

Contact Person:
Telephone:
Email:
Address:

1.

What geographic area did the project activity serve? (include county and ZIP code for each area)

2.

Please describe all of the SIDS/safe infant sleep outreach activities that you conducted during this grant cycle (January 9,
2017, through July 31, 2017). Be as specific as possible. Please use additional pages if needed.

•

Total Number of Events:

•

Total Number of Participants Who Attended Events:

All Activity Tracking Forms must be turned in at the Closing Meeting on August 4, 2017.
1

Alabama Safe Sleep Outreach Project

Activity
Example:
Safety Baby
Shower

Description

Event Date

Number of
Attendees

Desha County Health Unit
representatives partnered with
church officials from First Baptist
Church Day Care Center in McGehee
to train parents and child care
providers on safe infant sleep using
the Safe to Sleep® educational video
and print materials. The Bruce Family
Endowment provided a
supplementary in-kind donation for
this education initiative, which
covered meal expenses for training
participants.

1/9/2016

35

Activity
Audience
—
—
—
—

Expecting mothers
New parents
Grandparents
Church members

Encounter:
Awareness
vs.
Educational
Educational

All Activity Tracking Forms must be turned in at the Closing Meeting on August 4, 2017.
2

Alabama Safe Sleep Outreach Project
3.

Which safe infant sleep messages were the hardest for training participants to understand? Please explain.

4.

What parts of this project worked well and would you do again to make your outreach successful? Please explain.

5.

Do you feel you have the information and resources you need to raise awareness about ways to reduce the risk of SIDS and
to promote safe infant sleep in your community?

□
□

Yes
No

If no, what types of information or resources would be most helpful to you?

All Activity Tracking Forms must be turned in at the Closing Meeting on August 4, 2017.
3

Alabama Safe Sleep Outreach Project
6.

With 1 being not at all helpful and 5 being very helpful, check a box to describe how helpful you felt the following materials
were in your outreach work.
a.

b.

c.

d.

Promotion materials (such as flyer template, sample social media posts, sample advertisement)
1
Not at all helpful

2

3

4

5
Very helpful

□

□

□

□

□

1
Not at all helpful

2

3

4

5
Very helpful

□

□

□

□

□

Educational presentations

Event planning materials (such as tips and tricks handout, planning checklist)
1
Not at all helpful

2

3

4

5
Very helpful

□

□

□

□

□

Educational materials (such as educational flipbook, safe sleep brochure, one-page handout)
1
Not at all helpful

2

3

4

5
Very helpful

□

□

□

□

□

All Activity Tracking Forms must be turned in at the Closing Meeting on August 4, 2017.
4

OMB # 0925-0701
Expiration Date: 07/31/2017

Safe Sleep Outreach Required Forms Checklist for
Closing Meeting
Please bring all of these items to the closing meeting on August 4, 2017. Use this
checklist to make sure you have all of the required items.
Public reporting burden for this collection of information is estimated to average 1 minute 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: NIH, Project Clearance
Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0701). Do not
return the completed form to this address.

______ Completed Sign-In Sheets
______ Completed Safe Sleep Outreach Project Assessment Forms from event attendees
______ Completed Safe Sleep Outreach Project Activity Tracking Form
______ Signed Photo/Video Release Forms

All Sign-In Sheets, Activity Tracking Forms, and Project Assessment Forms
must be turned in at the Closing Meeting on August 4, 2017.

OMB # 0925-0701
Expiration Date: 07/31/2017

Alabama Safe Sleep Outreach Project
Sign-In Sheet
Public reporting burden for this collection of information is estimated to average 1 minute 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: NIH, Project
Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0701). Do not return the
completed form to this address.

Event Type:

Date: _______ /______ /_____
Month Day
Year

Location:
Name (please print)

Signature

Alabama Safe Sleep Outreach Project Sign-In Sheet
Name (please print)

Signature

Alabama Safe Sleep Outreach Project Sign-In Sheet
Name (please print)

Signature

OMB Number: 0925-0701
Expiration Date: 07/31/2017
Healthy Native Babies Project Train-the-Trainer Follow-Up Assessment
Thank you for participating in this follow up assessment. It should take no longer than 15 minutes to complete. The
questions are about your activities since attending the Healthy Native Babies Project Train-the Trainer session in [fill
in training location for each IHS Area cohort]. This assessment will refer to the Healthy Native Babies Project Train-the
Trainer session as ‘the Training’. You may want to refer to your calendar to answer questions about activities
conducted since attending the Training.

First, the following are general questions about your work.
1. Since attending the Training, has your job changed? That is, do you work for a different agency or organization,
have you changed positions within the same agency, or have your responsibilities changed substantially?
____Yes
____No  SKIP TO QUESTION 3
2. What type of work are you currently employed in? CHECK ALL THAT APPLY.
____Public Health Nursing
____Community Health Representative
____WIC
____Other Home Visiting (Healthy Start)
____OBGYN or Labor and Delivery
____Pediatrics
____Health Education and Promotion
____Behavioral Health
____Injury Prevention
____Child Care or Early Childhood Education
____Child Welfare, Protective Services, or Social Services
____Other Law Enforcement
____Other (Please tell us: _______________)
Please answer the rest of the questions on this page about your current position.

3. On average, in a year, how many of your clients or patients are parents or caregivers of American Indian/Alaska
Native infants?
____All
____Most
____About half
____A few
____None
____I do not provide direct service to patients or clients


Public reporting burden for this collection of information is estimated to average 15 minutes, 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN:
PRA (0925-0701). Do not return the completed form to this address.

4. On average, in a year, how many trainings for service providers do you conduct in your regular work? (If you do
not conduct training for service providers, please put a ‘0’ in the space below.)

_____ Trainings

Dissemination of Health Education Materials about SIDS and Other Sleep-Related Causes of Infant Death
Please answer the questions on this page about the entire period since you attended the training, even if your job has
changed.
5. Since attending the Training, which health education print materials, if any, have you created using the Healthy
Native Babies Project Toolkit Disk? CHECK ALL THAT APPLY.
____Brochures
____Flyers (8 ½ x 11 with white background)
____Posters (11 x 17 full color)
____Postcards
____Other materials (Please tell us: ____________________)
____None
6. Did you have any problems using the Healthy Native Babies Project Toolkit Disk?
____Yes (Please tell us what problems you had: ______________________________)
____No

7. Since attending the Training, have you ordered any of the following Healthy Native Babies Project materials
from the NICHD Information Resource Center? CHECK ALL THAT APPLY.
____ Safe Sleep for Your Baby Brochure
____Honor the Past, Learn for the Future Flyer
____Healthy Native Babies Project Workbook Packet
____Healthy Native Babies Project Facilitator’s Packet

8. Since attending the Training, which Healthy Native Babies Project print materials (customized materials or those
ordered from the NICHD Information Resource Center), if any, have you distributed in the communities where
you work? CHECK ALL THAT APPLY.
____Brochures
____Flyers (8 ½ x 11 with white background)
____Posters (11 x 17 full color)
____Postcards
____Other materials (Please tell us: ___________________)
____None

9. Since attending the Training, from what other source(s), if any, have you ordered or received health education
print materials about SIDS or other sleep-related causes of infant death risk-reduction?

10. Since attending the Training, have you distributed print materials on SIDS or other sleep-related causes of infant
death that you received from other sources in the communities where you work?
____Yes
____No

Risk-Reduction Education, Trainings, and Presentations on SIDS and Other Sleep-related Causes of Infant Death
11. Since attending the Training, which of the following activities addressing SIDS or other sleep-related causes of
infant death have you conducted? CHECK ALL THAT APPLY.
____Delivered risk-reduction education to parents or caregivers in a clinic, office, or other service delivery site
____Delivered risk-reduction education to parents or caregivers in their home
____Delivered risk-reduction education to a community group
____Conducted training for service providers on delivering risk-reduction education
____Conducted training for parents, caregivers, or community members on delivering risk-reduction education
to their peers
____Presented information to service providers
____Presented information to tribal leadership or other policy makers
____None
____Other activity. Please tell us: __________________________________

12. Since attending the Training, to how many of your patients or clients have you delivered risk-reduction
education about SIDS or other sleep-related causes of infant death?
___All patients/clients
___Most patients/clients
___About half of your patients/clients
___Few patients/clients
___None of your patients/clients
___I do not provide direct service to patients or clients

13. Since attending the Training, how many trainings have you conducted for service providers on delivering riskreduction education about SIDS and other sleep-related causes of infant death? (If you have not conducted any
training, please put a ‘0’ in the space below.)
___ Trainings

14. Since attending the Training, how many trainings have you conducted for parents, caregivers, or community
members on delivering risk-reduction education about SIDS and other sleep-related causes of infant death to
their peers? (If you have not conducted any training, please put a ‘0’ in the space below.)
___Trainings

Healthy Native Babies Project Support Materials and Follow up Activities
15. Since attending the Training, which files from the Resource Disk have you used? CHECK ALL THAT APPLY.
___PowerPoint Presentations
___Health Education Activities
___None
16. Since attending the Training, have you used the Healthy Native Babies Project Workbook?
____Yes
____No

Feedback on the Training
17. Please think back to the Training that you attended. What parts, if any, have been the most useful in preparing
you to conduct risk-reduction training for service providers on SIDS and other sleep-related causes of infant
death? CHECK ALL THAT APPLY.
_____Healthy Native Babies Project and SIDS risk-reduction overview
_____Overview of key messages for Healthy Native Babies Project activity workstations
_____Teach back demonstrations to my peers
_____Community outreach overview
_____Local training work plan development
_____Healthy Native Babies Project Workbook, Resource Disk, and Toolkit Disk
_____Networking with participants
_____None

18. What parts of the Training, if any, could be improved to better prepare you to conduct risk-reduction training for
service providers on SIDS and other sleep-related causes of infant death? CHECK ALL THAT APPLY.
_____Healthy Native Babies Project and SIDS risk-reduction overview
_____Overview of key messages for Healthy Native Babies Project activity workstations
_____Teach back demonstrations to my peers
_____Community outreach overview
_____Local training work plan development
_____Healthy Native Babies Project Workbook, Resource Disk, and Toolkit Disk
_____Networking with participants
_____None

19. Please tell us how we can improve the Training.

20. What challenges have you experienced in conducting health education or training on SIDS and other sleeprelated causes of infant death?

21. What successes have you achieved in conducting health education or training on SIDS and other sleep-related
causes of infant death?

Please select the option that best describes how much you agree or disagree with the statements below.
22.

I am confident in my overall knowledge of SIDS and other sleeprelated causes of infant death.

Strongly
Agree

Agree

Disagree

Strongly
Disagree

23.

I can educate parents and caregivers about SIDS and other sleeprelated causes of infant death.

Strongly
Agree

Agree

Disagree

Strongly
Disagree

24.

I can help parents and caregivers reduce the risk of SIDS and other
sleep-related causes of infant death.

Strongly
Agree

Agree

Disagree

Strongly
Disagree

25.

I can demonstrate how to make a baby’s sleep environment safer.

Strongly
Agree

Agree

Disagree

Strongly
Disagree

26.

I can train service providers to deliver risk-reduction education
about SIDS and other sleep-related causes of infant death.

Strongly
Agree

Agree

Disagree

Strongly
Disagree

27.

I can teach service providers to talk with mothers about how
smoking or second-hand smoke exposure can increase the risk of
SIDS.

Strongly
Agree

Agree

Disagree

Strongly
Disagree

28.

I can teach elders who smoke not to smoke inside a house or
vehicle when an infant is inside.

Strongly
Agree

Agree

Disagree

Strongly
Disagree

29.

I will conduct training for service providers on SIDS and other
sleep-related causes of infant death within the next three months.

Strongly
Agree

Agree

Disagree

Strongly
Disagree

30.

I will deliver risk-reduction education to parents or caregivers
about SIDS and other sleep-related causes of infant death within
the next three months.

Strongly
Agree

Agree

Disagree

Strongly
Disagree

I will give out Healthy Native Babies Project health education print
materials in the communities where I work within the next three
months.

Strongly
Agree

Agree

Disagree

Strongly
Disagree

31.

Thank you for completing this follow-up assessment. Your feedback will help us to improve the Healthy Native Babies
Project.

OMB Number: 0925-0701
Expiration Date: 07/31/2017

Healthy Native Babies Project
Materials Distribution Tracking Form
The purpose of this form is to provide a framework for reporting on your Healthy Native Babies Project
distribution activities funded by the resource stipend. Please call 1-888-996-9916 if you have any
questions.

Tribe/Organization Name:
Contact Name:
City:
State and Zip Code:
Phone Number: (Including Area Code)
Email:
IHS Area:

Resource Stipend Report Components
Please respond to each of the following sections.
I. Materials Distributed – Please describe type and number of Healthy Native Babies Project materials that
were made available for distribution, at locations or during events, and describe the number actually distributed
to the target population, if known.
Healthy Native Babies Project Setting or Event
(HNB) Material Type

# Provided to
Setting/ Event

Example: Poster
Example: Brochure

20
50

Various community locations
Tribal Home Visiting Project

# Distributed to
target audience
(if known)*
20
25

*The number distributed to target audience is the actual number of materials handed out. This number would be less than the
number provided to the setting/event if there were leftover copies. Provide an estimate if exact number is not known.

Public reporting burden for this collection of information is estimated to average 30 minutes, 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: NIH, Project Clearance Branch,
6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0701). Do not return the completed form to this address.

II. Activities – Describe the community outreach activities conducted with your Healthy Native Babies Project
resource stipend including the specific types of activities used to reach parents, caregivers, or hard to reach
groups. Use the table to report the number of individuals reached through the outreach activities.


Brief narrative:

Outreach Activity
(e.g., home visit, community event)

Number of Individuals Reached
Parents/
Caregivers

Elders

Community
at large

Service
Providers

Other:

III. Results of Activities – If you conducted assessments of your organization’s outreach activities that used
Healthy Native Babies Project materials, please describe your results. For example, please share the results of
satisfaction assessments, feedback from parents or service providers on the Healthy Native Babies Project
messages or materials, or pre and post-test results.


IV. Distribution Successes and Challenges – Describe the successes and challenges you experienced in
distributing Healthy Native Babies Project materials. Your responses will be used in the development of future
Healthy Native Babies Project activities and resources.
