0920-0879 PHICCS Phone Administration of Instrument - Word Version

Information Collections to Advance State, Tribal, Local and Territorial (STLT) Governmental Agency System Performance, Capacity, and Program Delivery

Attachment D - PHICCS Instrument (Word version)_revised

Public Health in Indian Country Capacity Scan Assessment (PHICCS)

OMB: 0920-0879

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0879 can be found here:

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Attachment D – PHICCS Instrument (Word Version)

OMB No. 0920-0879

Expiration Date 01/31/2021

P ublic Health in Indian Country Capacity Scan

Purpose

Thank you for agreeing to participate in the National Indian Health Board (NIHB) Tribal Public Health in Indian Country Capacity Scan. The information you share with the NIHB will be used to develop a report that will support and guide essential tribal public health service work in the areas of public health practice, technical support, and assessment of issues related to improving Indian health. This scan expands and builds upon a similar capacity assessment titled “2010 Tribal Public Health Profile: Exploring Public Health Capacity in Indian Country”. It will provide a more recent, comprehensive picture of the capacity of public health in Indian Country. Participation of each tribal health department in this capacity scan is critical to put forth a comprehensive picture of public health in Indian Country.

There are a total of 129 questions about the types of public health activities occurring within the community you serve. You may enter and exit the assessment as often as necessary to complete the questionnaire accurately. The estimated time to complete the assessment is 60 minutes.

At the end of the questionnaire, there is an opportunity to provide feedback to NIHB. Your feedback is encouraged as it will improve future assessments and scans of this nature. Given the diversity and uniqueness across tribal settings, some of the questions may not be worded in a manner that reflects the work that is occurring at your site. If this is the case, please feel free to use the text box at the end of the questionnaire to provide relevant information related to the tribal community you serve.

All responses will be kept secure, and results will be reported only in aggregate form. Data from this scan will be analyzed and published in a national-level report and made available on NIHB’s website. NIHB will report the findings of this scan from a national perspective; however, your tribal health entity will have access to your own data, which will allow you to compare your results to a national aggregate, and perhaps regionally, if you choose to share your data in your area.

PLEASE COMPLETE AND SUBMIT ALL OF YOUR RESPONSES BY [DATE].

This questionnaire falls under the work of a cooperative agreement between the Centers for Disease Control and Prevention and the National Indian Health Board. Through this agreement, the intent of this questionnaire is to inform tribal leaders and communities, and federal agencies on the overall scope of public health in Indian Country.

Your participation in this assessment is voluntary and you can stop the interview at any time. All information will be shared and reported in aggregate form.

If you have any questions, would like assistance, or would like to complete the scan over the phone, please contact Stephen Valliere at [email protected] or 202-507-4082.

Participants and other stakeholders may access the results at www.nihb.org, once data collection and analysis are completed.

Table of Contents

Section/Topic

Respondent Contact Information (Work Contact)

Demographic/Background Information

Public Health Activities

Public Health Workforce

Health Priorities and Needs

Public Health Governing Entity

Additional Comments

Respondent Contact Information (Work Contact)

Please provide your professional contact information.

Name ________________________________________________
Title ________________________________________________

Name of tribal health organization or intertribal health consortium for which you work_______________________________

Which tribes does Tribal Organization/Entity serve?
Work email ________________________________________________
Confirm work email ________________________________________________
Office or work phone ________________________________________________
Work street address ________________________________________________
City ________________________________________________
State ________________________________________________
Website URL (if none enter N/A) ________________________________________________

What type of organization/entity are you filling this out on behalf of? (select one)

Federally recognized tribe
Tribal health consortium
Other (please specify) ________________________________________________

Demographic/Background Information

Providing information on your Tribal Organization/Entity will aid NIHB's efforts to accurately describe who receives public health services from tribal entities.

1. Who receives public health services provided by Tribal Organization/Entity (check all that apply)

Enrolled members of any federally recognized tribe(s) within Tribal Organization/Entity’s service area
Non-enrolled members of a federally recognized tribe(s) (such as eligible dependents or descendants who receive benefits)
Members of a state-recognized tribe
Non-Indians (non-Indians living in a specified geographic area, veterans, spouses, tribal employees, etc.)
Other ________________________________________________

2. How many individuals does Tribal Organization/Entity provide public health services to in a calendar year? Public health services may include providing immunizations and disease screenings, or providing outreach and education materials to the community-at-large, such as at a health fair.

________________________________________________________________

3. Is Tribal Organization/Entity a direct service tribe?

Yes
No
Don't know / Unsure

4. What is the maximum distance (in miles) an individual within your service area would have to travel to access the nearest non-tribal (city, county, or state) public health department?

0 to 25 miles
25 to 50 miles
50 to 75 miles
75 miles to 100 miles
Greater than 100 miles

5. How many states overlap the Tribal Organization/Entity’s service area?

1 state
2 states
3 states

6. How many non-tribal (city, county, and/or state) public health departments are located within your organization’s service area?

1 non-tribal health department
2 - 5 non-tribal health departments
6 - 10 non-tribal health departments
More than 10 non-tribal health departments
Don't know / Unsure

Public Health Activities

Providing this information will aid NIHB's efforts to assess the tribal public health system's strengths and gaps, and to prioritize areas for public health program development.

The following set of questions asks about both immunization and screening services offered in the Tribal Organization/Entity’s service area.

7. Have child immunization services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q8 If Have child immunization services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q9 If Have child immunization services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

8. Who provided the child immunization services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

9. Have adult immunization services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q10 If Have adult immunization services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q11 If Have adult immunization services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

10. Who provided the adult immunization services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

11. Have alcohol and other drug screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q12 If Have alcohol and other drug screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q13 If Have alcohol and other drug screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

12. Who provided the alcohol or other drug screening services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

13. Have asthma screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q14 If Have asthma screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q15 If Have asthma screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

14. Who provided the asthma screening services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

15. Have body mass index (BMI) screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q16 If Have body mass index (BMI) screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q17 If Have body mass index (BMI) screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

16. Who provided the body mass index (BMI) screening services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

17. Have cancer screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q18 If Have cancer screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q19 If Have cancer screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

18. Who provided the cancer screening services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

19. Have cardiovascular disease screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q20 If Have cardiovascular disease screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q21 If Have cardiovascular disease screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

20. Who provided the cardiovascular disease screening services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

21. Have commercial tobacco use screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q22 If Have commercial tobacco use screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q23 If Have commercial tobacco use screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

22. Who provided the commercial tobacco use screening services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

23. Have type II diabetes screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q24 If Have type II diabetes screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q25 If Have for type II diabetes screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

24. Who provided the type II diabetes screening services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

25. Have homelessness screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q26 If Have homelessness screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q27 If Have homelessness screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

26. Who provided the homelessness screening services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

27. Have hunger screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q28 If Have hunger screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q29 If Have hunger screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

28. Who provided the hunger screening services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

29. Have mental health screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q30 If Have mental health screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q31 If Have mental health screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

30. Who provided the mental health screening services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

31. Have sexually transmitted infections (STIs) screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q32 If Have sexually transmitted infections (STIs) screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q33 If Have sexually transmitted infections (STIs) screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

32. Who provided the sexually transmitted infections (STIs) screening services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

33. Have suicide screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q34 If Have suicide screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q35 If Have suicide screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

34. Who provided the suicide screening services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

35. Have trauma screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q36 If Have trauma screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q37 If Have trauma screening services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

36. Who provided the trauma screening services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

The following questions ask about prevention and/or education activities offered in the Tribal Organization/Entity’s service area.

37. Have alcohol and other drugs prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q38 If Have alcohol and other drugs prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q39 If Have alcohol and other drugs prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

38. Who provided the alcohol and other drugs prevention and/or education activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

39. Have cancer prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q40 If Have cancer prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q41 If Have cancer prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

40. Who provided the cancer prevention and/or education activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

41. Have cardiovascular disease prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q42 If Have cardiovascular disease prevention and/or education activities for cardiovascular disease occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q43 If Have cardiovascular disease prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

42. Who provided the cardiovascular disease prevention and/or education activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

43. Have commercial tobacco use prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q44 If Have commercial tobacco use prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q45 If Have commercial tobacco use prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

44. Who provided the commercial tobacco use prevention and/or education activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

45. Have diabetes prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q46 If Have diabetes prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q47 If Have diabetes prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

46. Who provided the diabetes prevention and/or education activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

47. Have injury prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q48 If Have injury prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q49 If Have injury prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

48. Who provided the injury prevention and/or education activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

49. Have suicide prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q50 If Have suicide prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q51 If Have suicide prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

50. Who provided the suicide prevention and/or education activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the Tribe (3)
Tribal Organization (4)
Tribal Epidemiology Center (5)
Urban Indian Health Program (6)
Indian Health Service (7)
Local Health Department (8)
State Health Department (9)
Private and/or Non Profit Health Service Organization (10)
Other (11)

51. Have emergency preparedness education activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q52 If Have emergency preparedness prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q53 If Have emergency preparedness prevention and/or education activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

52. Who provided the emergency preparedness education activities in the Tribal Organization/Entity’s service area in the past year? (Choose all hat apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

53. Have mental health education activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q54 If Have mental health education activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q55 If Have mental health education activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

54. Who provided the mental health education activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

55. Have occupational/worker safety education activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q56 If Have occupational/worker safety education activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q57 If Have occupational/worker safety education activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

56. Who provided the occupational/worker safety education activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

57. Have reproductive health education activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q58 If Have reproductive health education activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q59 If Have reproductive health education activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

58. Who provided the reproductive health education activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

59. Have trauma education activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q60 If Have trauma education activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q61 If Have trauma education activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

60. Who provided the trauma education activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the Tribe (3)
Tribal Organization (4)
Tribal Epidemiology Center (5)
Urban Indian Health Program (6)
Indian Health Service (7)
Local Health Department (8)
State Health Department (9)
Private and/or Non Profit Health Service Organization (10)
Other (11)

61. Have weight-related health education activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q62 If Have weight-related health education activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q63 If Have weight-related health education activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

62. Who provided the weight-related health education activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

The following questions ask about data collection, epidemiology, and/or surveillance activities offered in the Tribal Organization/Entity’s service area.

63. Have behavioral risk factors data collection, epidemiology, and/or surveillance activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q64 If Have behavioral risk factors data collection, epidemiology, and/or surveillance occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q65 If Have behavioral risk factors data collection, epidemiology, and/or surveillance occurred in the Tribal Organization/Entity’s service area in the past year? = No

64. Who provided the behavioral risk factors data collection, epidemiology, and/or surveillance activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

65. Have injury data collection, epidemiology, and/or surveillance activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q66 If Have injury data collection, epidemiology, and/or surveillance occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q67 If Have injury data collection, epidemiology, and/or surveillance occurred in the Tribal Organization/Entity’s service area in the past year? = No

66. Who provided the injury data collection, epidemiology, and/or surveillance activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

67. Have environmental illness data collection, epidemiology, and/or surveillance activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q68 If Have environmental health data collection, epidemiology, and/or surveillance occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q69 If Have environmental health data collection, epidemiology, and/or surveillance occurred in the Tribal Organization/Entity’s service area in the past year? = No

68. Who provided the environmental illness data collection, epidemiology, and/or surveillance activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

69. Have foodborne illness data collection, epidemiology, and/or surveillance activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q70 If Have foodborne illness data collection, epidemiology, and/or surveillance occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q71 If Have foodborne illness data collection, epidemiology, and/or surveillance occurred in the Tribal Organization/Entity’s service area in the past year? = No

70. Who provided the foodborne illness data collection, epidemiology, and/or surveillance activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

71. Have data collection, epidemiology, and/or surveillance activities for other communicable or infectious diseases occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q72 If Have data collection, epidemiology, and/or surveillance for other communicable or infectious diseases occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q73 If Have data collection, epidemiology, and/or surveillance for other communicable or infectious diseases occurred in the Tribal Organization/Entity’s service area in the past year? = No

72. Who provided the data collection, epidemiology, and/or surveillance activities for other communicable or infectious diseases in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

73. Have chronic disease data collection, epidemiology, and/or surveillance activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q74 If Have chronic disease data collection, epidemiology, and/or surveillance occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q75 If Have chronic disease data collection, epidemiology, and/or surveillance occurred in the Tribal Organization/Entity’s service area in the past year? = No

74. Who provided the chronic disease data collection, epidemiology, and/or surveillance activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

75. Have syndromic surveillance data collection, epidemiology, and/or surveillance activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q76 If Have syndromic surveillance data collection, epidemiology, and/or surveillance activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q77 If Have syndromic surveillance data collection, epidemiology, and/or surveillance activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

76. Who provided the syndromic surveillance data collection, epidemiology, and/or surveillance activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

77. Have other morbidity data collection, epidemiology, and/or surveillance activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q78 If Have other morbidity data collection, epidemiology, and/or surveillance occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q79 If Have other morbidity data collection, epidemiology, and/or surveillance occurred in the Tribal Organization/Entity’s service area in the past year? = No

78. Who provided the other morbidity data collection, epidemiology, and/or surveillance activities, in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

79. Have vital statistics data collection, epidemiology, and/or surveillance activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q80 If Have vital statistics data collection, epidemiology, and/or surveillance occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q81 If Have vital statistics data collection, epidemiology, and/or surveillance occurred in the Tribal Organization/Entity’s service area in the past year? = No

80. Who provided the vital statistics data collection, epidemiology, and/or surveillance activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

The following questions ask about environmental health regulation, inspection, or licensing activities offered in the Tribal Organization/Entity’s service area.

81. Have facilities regulation, inspection, or licensing activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q82 If Have facilities regulation, inspection, or licensing activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q83 If Have facilities regulation, inspection, or licensing activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

82. Who provided the facilities regulation, inspection, or licensing activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

83. Have medical marijuana regulation, inspection, or licensing activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q84 If Have medical marijuana regulation, inspection, or licensing activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q85 If Have medical marijuana regulation, inspection, or licensing activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

84. Who provided the medical marijuana regulation, inspection, or licensing activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

85. Have occupational/worker safety and health regulation, inspection, or licensing activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q86 If Have occupational/worker safety and health regulation, inspection, or licensing activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q87 If Have occupational/worker safety and health regulation, inspection, or licensing activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

86. Who provided the occupational/worker safety and health regulation, inspection, or licensing activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

The following questions ask about specific and particular environmental health services or activities offered in the Tribal Organization/Entity’s service area.

87. Have environmental health services or activities on climate issues, climate change, or environmental impact occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q88 If Have environmental health services or activities on climate issues, climate change, or environmental impact occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q89 If Have environmental health services or activities on climate issues, climate change, or environmental impact occurred in the Tribal Organization/Entity’s service area in the past year? = No

88. Who provided the environmental health services or activities on climate issues, climate change, or environmental impact in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

89. Have food safety training/education services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q90 If Have training or education services or activities for food safety occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q91 If Have training or education services or activities for food safety occurred in the Tribal Organization/Entity’s service area in the past year? = No

90. Who provided the food safety training/education services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

91. Have groundwater protection services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q92 If Have groundwater protection services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q93 If Have groundwater protection services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

92. Who provided the groundwater protection services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

93. Have hazardous waste disposal services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q94 If Have hazardous waste disposal services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q95 If Have hazardous waste disposal services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

94. Who provided the hazardous waste disposal services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

95. Have air quality monitoring services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q96 If Have air quality monitoring services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q97 If Have air quality monitoring services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

96. Who provided the air quality monitoring services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

97. Have public water supply safety services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q98 If Have public water supply safety services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q99 If Have public water supply safety services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

98. Who provided the public water supply safety services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

99. Have sewer/septic pollution services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q100 If Have sewer/septic pollution services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q101 If Have sewer/septic pollution services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

100. Who provided the sewer/septic pollution services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

101. Have vector control services or activities occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q102 If Have vector control services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q103 If Have vector control services or activities occurred in the Tribal Organization/Entity’s service area in the past year? = No

102. Who provided the vector control services or activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

103. Have any environmental health regulation, inspection, or licensing activities other than those listed above occurred in the Tribal Organization/Entity’s service area in the past year?

Yes (1)
No (2)
Unsure (3)

Skip To: Q104 If Have any environmental health regulation, inspection, or licensing services or activities other than those listed above occurred in the Tribal Organization/Entity’s service area in the past year? = Yes

Skip To: Q105 If Have any environmental health regulation, inspection, or licensing services or activities other than those listed above occurred in the Tribal Organization/Entity’s service area in the past year? = No

104. Who provided the environmental health regulation, inspection, or licensing activities in the Tribal Organization/Entity’s service area in the past year? (Choose all that apply.)

${Q1/ChoiceTextEntryValue/10} (2)
Entity/Department other than ${Q1/ChoiceTextEntryValue/10} located within the tribe (3)
Tribal organization (4)
Tribal epidemiology center (5)
Urban Indian health program (6)
Indian Health Service (7)
Local health department (8)
State health department (9)
Private and/or non-profit health service organization (10)
Other (11)

The following questions ask about assessment, performance improvement, and accreditation activities offered in the Tribal Organization/Entity’s service area.

105. Has Tribal Organization/Entity developed a community health assessment? By “health assessment” we mean the systematic collection and analysis of data and information for use in educating and mobilizing communities, developing priorities, garnering resources or using resources in different ways, adopting or revising policies, and planning actions to improve the population’s health.

Yes, within the last 5 years
Yes, but more than 5 years ago
Yes, currently in development
No, but plan to in the next year
No

106. Has Tribal Organization/Entity developed or participated in developing a community health improvement plan for your community? A community health improvement plan is a long-term, systematic effort to address public health problems on the basis of the results of community health assessment activities and the community health improvement process.

Yes, within the last 5 years
Yes, but more than 5 years ago
Yes, currently in development
No, but plan to in the next year
No

107. Do you have a community health improvement plan that was developed using the results of a community health assessment?

Yes
No (if checked, skip to question 109)

108. Do you plan to update your community health improvement plan within the next 3 years?

109. Has Tribal Organization/Entity developed an organizational strategic plan?

Yes, within the last 5 years
Yes, but more than 5 years ago
Yes, currently in development
No, but plan to in the next year
No

110. Does your Tribal Organization/Entity use the core competencies for public health professionals developed by the Council on Linkages in any of the following ways? (Select all that apply.)

Assessing staff training needs
Conducting staff performance evaluations
Developing staff training plans
Writing position descriptions
Other_________________
No

111. Which of the following statements best characterizes your Tribal Organization/Entity’s current quality improvement activities? (Select only one.)

We have implemented a formal quality improvement program entity-wide.
We are implementing formal quality improvement activities in specific programmatic or functional areas of the entity, but not on an entity-wide basis.
Our quality improvement activities are informal or ad-hoc in nature.
We are not currently involved in quality improvement activities.

112. What is the status of Tribal Organization/Entity’s implementation of its quality improvement plan?

Not yet implemented
Implemented in the past year
Implemented more than 1 year ago; a written evaluation on progress toward quality improvement plan goals, objectives, or targets has not yet been completed
Implemented more than 1 year ago, with one or more completed written evaluations on progress toward quality improvement plan goals, objectives, or targets

113. Has Tribal Organization/Entity established a performance management system?

Yes, within the last 5 years
Yes, but more than 5 years ago
Yes, currently in development
No, but plan to in the next year
No

114. Which of the following best describes Tribal Organization/Entity with respect to engagement in the Public Health Accreditation Board’s (PHAB’s) national public health accreditation program?

Tribal Organization/Entity has achieved accreditation.
Tribal Organization/Entity is in the process of formally applying (i.e., has registered in e-PHAB and is submitting an application, uploading documentation, preparing for a site visit, etc.).

Tribal Organization/Entity plans to apply but has not yet submitted an application.
Tribal Organization/Entity has not decided whether to apply for accreditation.
Tribal Organization/Entity is not familiar with accreditation.
PHAB accreditation is not applicable.

The next set of questions deals with the Tribal Organization/Entity’s communication strategies and registries.

115. How did Tribal Organization/Entity communicate public health information to your tribal community in the past year? (Check all that apply.)

Social media (Facebook, Twitter)
Website
Text alerts
Tribal newsletter
Email
Radio
Direct mailing
Posters
Billboards
In-person interaction
Other ________________________________________________

116. Indicate if Tribal Organization/Entity's has any of the following registries

	Yes	No	Don’t Know	N/A
Immunization registry
Public health registry (including cancer registry)
Clinical data registry

Public Health Workforce

Providing this information will aid efforts to understand public health workforce needs in Indian Country.

117. Please indicate the current number of public health staff members (for example, staff providing public health services such as prevention, rather than staff providing clinical services and treating illness after onset). Please include temporary and contract workers. Please also provide this information expressed as the number of full-time equivalent (FTE) public health staff members in Tribal Organization/Entity. A full-time equivalent works 40 hours a week in public health and should be counted as 1.0 FTE. An employee who works 20 hours a week on public health activities should be counted as one 0.5 FTE. So, you could have 5 staff members (people) who make up 4.5 FTEs (4 people are 1.0 FTEs and one person is a 0.5 FTE)

Number of staff members: __________

Number of full-time equivalents (FTEs): _______

118. In the below table, please indicate Tribal Organization/Entity’s current number of positions funded in each occupational classification listed. Employees who provide or support public health services in each of these classifications should be listed in full-time equivalent (FTE) units.

An employee who works 40 hours a week on public health activities should be counted as 1.0 FTE.

An employee who works 10 hours a week on public health should be counted as .25 FTE.

NOTE: Column (total FTE positions funded (c) should equal the sum of funded FTE positions filled (d) and funded FTE positions vacant, i.e., (c) = (d) + (e)

Definitions:

(a) Occupational Classifications	(b) Descriptions and Examples of Occupational Classifications	(c) Total Number of FTE Positions Funded	(d) Number of Funded FTE Positions Filled	(e) Number of Funded FTE Positions Vacant	(f) How Many Additional Funded FTEs Are Needed
Agency Leadership / Upper management	Oversees the operations of the overall agency or a major subdivision of public health services. Includes all top agency executives regardless of education or licensing (e.g., health commissioner, health officer, public health administrator, deputy director, bureau chief, division director).
Business and Financial Operations Staff	Performs specialized work in areas of business, finance, accounting, human resources, information technology, and legal issues (e.g., financial analyst, human resources specialist, grant and contracts manager, legal personnel, computer system analyst, network and database administrator).
Community Health Aides (CHAs)	Assist health professionals in communicating with members of the community seeking medical care and consultation.
Community Health Representatives (CHRs)	Medically-guided, trained professionals who provide tribal community-driven healthcare, which may include traditional Native concepts in their work.
Preparedness Staff	Manages or develops the plans, procedures, and training programs involving the public health response to all-hazards events (e.g., emergency preparedness coordinator, incident manager, emergency preparedness manager, emergency preparedness specialist).
Environmental Health Worker	Investigates, monitors, and identifies problems or risks that may affect the environment (e.g., food safety, air and water quality, and solid waste) and, consequently, the health of an individual or group. May include environmentalist, environmental health specialist, scientist, engineer, occupational health worker or technician, sanitarian, inspector.
Epidemiologist/ Statistician	Conducts on-going surveillance, field investigations, analytic studies and evaluations of disease occurrence and disease potential to make recommendations on appropriate interventions. May also collect data and report vital statistics (e.g., epidemiologist, biostatistician, public health scientist/researcher).
Information Technology (IT)	Develops, maintains, and provides support for computer systems, software, networks, and any associated technologies used for the processing and distribution of data (e.g., web developer, database administrator, network administrator, computer support specialist).
Laboratory Worker	Plans, designs, and implements laboratory testing procedures, and performs analyses that provide data to diagnose, treat, and monitor disease and environmental hazards (e.g., laboratorian, laboratory scientist, laboratory technician, laboratory aide or assistant, medical technologist).
Legal Counsel	A legal professional who provides support to a tribal entity on cases pertaining to tribal public health (e.g., attorney, lawyer, chief legal officer, general counsel).
Behavioral Health Staff	Develops and implements strategies to improve community mental health status. May also provide direct behavioral health services to clients regarding mental, social, and behavioral issues (e.g., psychiatrist, psychologist, public health social worker, HIV/AIDS counselor, behavioral counselor, community organizer, social services counselor, and mental health and substance abuse counselor.)
Nurse Practitioner	Licensed nurse who identifies persons or groups at risk of illness or disability and develops, implements, and evaluates programs or interventions designed to prevent, treat, or improve such risks, and may provide direct medical services to clients.
Nutritionist	Develops and implements interventions related to nutrition, the nutrition environment, and food and nutrition policy. May also provide nutritional counseling and evaluate the effectiveness of current interventions (e.g., dietician, nutritionist, WIC lactation staff, WIC nutrition staff).
Occupational Health Therapist	Promotes independence for people living with injuries, illnesses, disabilities, or psychological conditions and enables them to engage in daily activities with personal meaning and value.
Office and Administrative Support	Performs administrative tasks and clerical duties (e.g., administrative assistant, secretary, receptionist, office clerk, maintenance staff, operator).
Oral Health Professional	Diagnoses and treats problems with teeth, gums, and the mouth. May also educate individuals or groups on proper oral health activities such as diet choices affecting oral health; (e.g., public health dentist, dental hygienist, and dental assistant.
Quality Improvement Professional	Works collaboratively within public health agency to lead and establish appropriate performance management and quality improvement systems. May also play a lead role in systems assessment and preparing the agency for national public health accreditation (e.g., performance management and quality improvement director, performance improvement manager, performance improvement director).
Physician Assistants	Licensed professional who identifies persons or groups at risk of illness or disability and develops, implements, and evaluates programs or interventions designed to prevent, treat, or improve such risks, and may provide direct medical services to clients.
Public Health Informatics Specialist	Public health professional who applies informatics principles and standards to improve population health (e.g., public health information systems specialist, public health informatician).
Public Health Educator	Develops and implements educational programs and strategies to support and modify health-related behaviors of individuals and communities, and promotes the effective use of health programs and services (e.g., health educator, health education coordinator, health education specialist).
Public Health Nurse	Registered nurse conducting public health nursing (e.g., school nurse, community health nurse).
Public Health Physician	Licensed physician who identifies persons or groups at risk of illness or disability and develops, implements, and evaluates programs or interventions designed to prevent, treat, or improve such risks, and may provide direct medical services to clients (e.g., licensed physician, preventive medicine physician). Excludes psychiatrists and psychologists.
Public Information Specialist	Serves as communications coordinator or spokesperson for the agency to provide information about public health issues to the media and public (e.g., public information officer, public information specialist).
Workforce Development Coordinator	Executes workforce development events and activities that promote job creation, workforce recruitment, and retention in industries, and advocates for the interest of employers in relation to workforce and education.
Other

119. What are Tribal Organization/Entity's current public health workforce development needs? For example, training or professional development needs.

1. ________________________________________________
2. ________________________________________________
3. ________________________________________________
4. ________________________________________________
5. ________________________________________________

Public Health Needs and Priorities

Public Health Needs
Providing this information will inform NIHB's understanding of the public health needs and priorities in Indian Country.

120. From the list below, please rank Tribal Organization/Entity's top 5 public health issues (Number 1 being most critical).

______ Accidents or unintentional injuries

______ Cancer

______ Diabetes

______ Heart disease

______ Infectious disease (not including Influenza)

______ Influenza and pneumonia

______ Kidney disease

______ Liver disease

______ Respiratory disease

______ Stroke

______ Substance misuse

______ Suicide

______ Other (please specify)

121. From the list below, please rank Tribal Organization/Entity's priorities as they relate to non-programmatic and infrastructure-building capacities and activities (Number 1 being most important and 11 least important).

______ Data and assessment

______ Enforcement

______ Evaluation

______ Health education and health promotion

______ Partnership development

______ Planning

______ Policy development

______ Quality improvement and performance management

______ Research

______ Surveillance and investigation

______ Workforce development

122. What additional resources do you need to improve public health within the tribal communities you serve?

________________________________________________________________

123. What can the Centers for Disease Control and Prevention do to assist tribal organizations and entities in advancing tribal public health?

________________________________________________________________

124. What can other federal agencies do to assist tribal organizations and entities in advancing tribal public health?

________________________________________________________________

125. What can the state (or states) do to assist tribal organizations and entities in advancing tribal public health?

________________________________________________________________

Public Health Authority

Providing this information will aid NIHB's efforts in understanding how tribal public health is governed.

126. In terms of governance, what entity provides oversight and direction for Tribal Organization/Entity? (Choose all that apply.)

Board of health/health board
Board of directors
Tribal chief executive officer (CEO)
Tribal governance organization (such as consortium)
We do not have a governing entity.
Other (please specify) ________________________________________________

127. Are any of the following present within your tribal service area, as enacted by the tribe?

	Yes	No	Don’t Know	N/A
Public health regulations
Public health codes
Taxes for public health (such as a junk food tax)
Public health levy
Fees related to public health
Policies, goals, and priorities for public health in the community

Additional Comments

128. Please use this space to provide any additional comments or information you wish to share.

129. We are interested in your suggestions about how NIHB can support public health capacity and invite you to share your perspectives with us here.

Final Assessment Submission

This is the end of the assessment. Thank you.

Glossary

Cancer screening: Screening tests can help find cancer at an early stage, before symptoms appear. Screening tests include physical exam and history, laboratory test, imaging procedures, and genetic tests. This includes all forms of cancer such as breast, cervical, colorectal, etc.

Cardiovascular disease screening: Cardiovascular disease generally refers to conditions that involve narrowed or blocked blood vessels that can lead to a heart attack, chest pain (angina), or stroke. Examples of ways to screen for cardiovascular disease are blood pressure and cholesterol screenings.

Chronic disease: A chronic disease is one lasting 3 months or more, (definition of the U.S. National Center for Health Statistics) and generally cannot be prevented by vaccines or cured by medication, nor do they just disappear. Examples include diabetes and heart disease.

Community health assessment: Community health assessment is a systematic examination of the health status indicators for a given population that is used to identify key problems and assets in a community. The ultimate goal of a community health assessment is to develop strategies to address the community’s health needs and identified issues. A variety of tools and processes may be used to conduct a community health assessment; the essential ingredients are community engagement and collaborative participation.

Community health improvement plan: A community health improvement plan is a long-term, systematic effort to address public health problems on the basis of the results of community health assessment activities and the community health improvement process. A plan is typically updated every 3 to 5 years.

Direct service tribe: A tribe that receives their healthcare through the Indian Health Service.

Environmental illness: Illnesses and diseases that can be directly attributed to the environmental, such as skin cancer from excessive exposure to sunlight.

Environmental health regulation, inspection, or licensing activities: Examples include but are not limited to the following: beaches and public swimming areas, biomedical waste, indoor air quality, lead inspection, marine and aquatic life, outdoor air quality monitoring, private drinking water, public drinking water, septic tank systems, solid waste disposal sites, solid waste haulers, swimming pools (public).

e-PHAB: e-PHAB is the information system developed by the Public Health Accreditation Board to support national public health department accreditation.

Facilities regulation, inspection, or licensing activities: Examples include but are not limited to the following: assisted living or group homes campgrounds & RVs, childcare facilities, emergency medical services, food processing, food service establishments (including cafes, restaurants, mobile food services), healthcare clinics, hospice, hospitals, hotels and motels, long-term care facilities, nursing homes, recreational facilities, and schools.

Federal agencies: Examples of Federal Agencies that provide public health services include the USDA, HUD, CDC, IHS, EPA, etc.

Federally recognized tribes: Indian tribes are self-governing entities that are acknowledged as such by the United States. The primary method of obtaining federal recognition is by meeting the established federal requirement process outlined by the U.S. Department of the Interior. Currently, there are 573 federally recognized tribes.

Full-time equivalent (FTE): An FTE is the hours worked by one employee on a full-time basis. The concept is used to convert the hours worked by several part-time employees into the hours worked by full-time employees.

1.0 FTE = 40 hours a week or full-time

0.60 FTE = 24 hours a week or 3 full days, 8 hours a day

0.20 FTE = 8 hours a week or 1 full day, 8 hours a day

Homelessness screening: Refers to procedures in which a standardized instrument or protocol is used to identify individuals who may be at risk for or are homeless.

Hunger screening: Refers to procedures such as standardized surveys or protocols used to identify individuals who do not have consistent access to enough food for an active, healthy life.

Indian Health Service (IHS): The Indian Health Service (IHS), an agency within the Department of Health and Human Services, is responsible for providing federal health services to American Indians and Alaska Natives.

Infectious Disease: Infectious diseases are disorders caused by organisms — such as bacteria, viruses, fungi or parasites. Examples include influenza, viral hepatitis and tuberculosis.

Local health department: A local health department is a governmental body serving a jurisdiction or group of jurisdictions geographically smaller than a state and recognized as having the primary statutory authority to promote and protect the public's health and prevent disease in humans. This authority is defined by the state's constitution, statute, or regulations, or established by local ordinance or through formal local cooperative agreement or mutual aid. The entity may be a locally governed health department, a local entity of a centralized state health department, or a city, city-county, county, district, or regional health department.

Mental health screening: Refers to procedures in which a standardized survey or protocol is used to identify individuals who may be at risk for, or have undiagnosed mental health conditions, such as depression and anxiety.

Organizational strategic plan: A strategic plan results from a deliberate decision-making process and defines where an organization is going. The plan sets the direction for the organization and, through a common understanding of the mission, vision, goals, and objectives, provides a template for all employees and stakeholders to make decisions that move the organization forward.

Other morbidity: Other morbidity can include you did not include in your responses to the data collection questions. Examples could include disabilities, birth defects or mental illnesses.

Performance management system: A performance management system is a single, comprehensive approach of using objectives and measurement to evaluate performance of programs, policies, and processes, and achievement of outcome targets for the tribal health department.

Private and/or non-profit health service organization: An entity not operated by the tribe. Examples include the following: non-tribal hospital, national organization.

Public health: Public health focuses on the population/community rather than the individual. Emphasis is on disease prevention and health promotion.

Public health accreditation: Accreditation for public health departments is defined as—

1. The development and acceptance of a set of national public health department accreditation standards;

2. The development and acceptance of a standardized process to measure public health department performance against those standards;

3. The periodic issuance of recognition for public health departments that meet a specified set of national accreditation standards; and

4. The periodic review, refining, and updating of the national public health department accreditation standards and the process for measuring and awarding accreditation recognition.

Public Health Accreditation Board (PHAB): The Public Health Accreditation Board is the national accrediting organization for public health departments. A non-profit organization, PHAB is dedicated to advancing the continuous quality improvement of tribal, state, local, and territorial public health departments.

Public health workforce development needs: An adequate supply of well-trained, public health workers (e.g., health educators, sanitarians) is necessary to improve health outcomes. (i.e., healthier people). An assessment of needs is plan for training, skill development and performance of public health workers.

Quality improvement plan: Quality improvement in public health is the use of a deliberate and defined improvement process, such as Plan-Do-Check-Act, which is focused on activities that are responsive to community needs and improving population health. It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes that achieve equity and improve the health of the community.

Sexually transmitted infection (STIs) screening: Refers to procedures in which standardized protocols are used to identify individuals who may be at risk for or have undiagnosed sexually transmitted infections, such as HIV/AIDs or syphilis

State health department: A state health department is a governing entity with primary statutory authority to promote and protect the public's health and prevent disease in humans. This authority is defined by state constitution, statutes or regulations, or is established by executive order. State health departments may be part of an umbrella organization, super public health agency, or super agency that oversees public health functions as well as other government functions.

Suicide screening: Refers to procedures in which a standardized instrument or protocol is used to identify individuals who may be at risk for, or have undiagnosed suicide.

Syndromic surveillance: The continuous, systematic collection, analysis, and interpretation of health-related data. Syndromic surveillance has been used for early detection of outbreaks; to follow the size, spread, and tempo of outbreaks; to monitor disease trends; and to provide reassurance that an outbreak has not occurred.

Trauma screening: Refers to procedures in which standardized instruments or protocols are used to identify individuals who may be at risk for trauma, or have undiagnosed trauma. Examples of trauma include elder abuse, domestic violence, and sexual abuse.

Tribal epidemiology center: Tribal epidemiology centers are Indian Health Service, division-funded organizations that serve American Indian and Alaska Native tribal and urban communities by managing public health information systems, investigating diseases of concern, managing disease prevention and control programs, responding to public health emergencies, and coordinating these activities with other public health authorities.

Tribal health consortiums: Consortiums of tribal regional health organizations that are designed to meet the unique needs of American Indians and Alaska Natives living in their areas. They aim to provide better care and service for AI/ANs in partnership than any single organization could. Tribal health consortiums may include, but are not limited to, tribal governments and programs, regional health consortiums, area Indian health boards, tribal epidemiology centers, tribal non-profit organizations, tribal health associations, and additional tribal or local entities.

Tribal organization: the recognized governing body of any Indian Tribe, or any legally established organization of Indians which is controlled, sanctioned, or chartered by such a governing body or which is democratically elected by adult members of the Indian community to be served by such organization and which includes the maximum participation of Indians in all phases of its activities: provided, that, in any case where a contract is let or a grant made to an organization to perform services benefiting more than one Indian tribe, the approval of each such Indian tribe shall be a prerequisite to the letting or making of such contract or grant. Examples include: Area Indian Health Board, consortia of tribes, does not include tribal epidemiology centers.

Understaffed: Additional staff are needed for this role; there are no resources for it.

Urban Indian Health Program: Urban Indian health centers are designated as federally qualified health centers and provide comprehensive primary care and related services to American Indians and Alaska Natives. The facilities are owned or leased by Urban Indian organizations and receive grant and contract funding through Title V of the Indian Health Care Improvement Act.

Vacant: Have money for the position; position currently unstaffed.

CDC estimates the average public reporting burden for this collection of information as 60 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 burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0879).

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File Title	PHICCS Newest Revisions 9/13/17
Author	Qualtrics
File Modified	0000-00-00
File Created	2021-01-20