Program Survey

Attachment B: PROGRAM Survey INSTRUMENT AND
SUPPLEMENTARY DOCUMENTS

B1. PROGRAM SURVEY

OMB Control No: XXX-XXX

Expiration Date:  XX/XX/XXX

WISEWOMAN Program Survey

Public Burden Statement: Public reporting burden of this collection of information is estimated to average 60 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 Office of Management and Budget control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

INTRODUCTION AND CONSENT

Since 1995, the Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program has provided women with services to support prevention, management, and treatment of cardiovascular disease. Your input on the experiences of your WISEWOMAN program enables us to better understand how programs are supporting WISEWOMAN participants and the most effective ways that programs are doing so.

This survey should take approximately 60 minutes to complete. Participation in the survey is completely voluntary and you may choose to skip any question. Your responses will be kept private and used only for research purposes. The evaluation will not identify individuals or organizations in its reports to the Centers for Disease Control and Prevention (CDC). Your answers will not have any impact on the funding or any other support that your WISEWOMAN program and agency may receive.

To expedite completion of the survey, we recommend that you have your work plan, annual reports, and other program and policy documents (such as provider contracts and requirements) easily accessible as you go through the survey.

When you have finished responding, save and email the completed survey to [email protected]

If you have any questions about the survey, please do not hesitate to contact us at [email protected]. If you have questions about the research, contact Michaela Vine at (617) 674-8358 or by email at [email protected].

By completing the survey and submitting your responses, you are confirming that you understand the information you provide will be kept private, used only for research purposes, and that your answers will be combined with the responses of other WISEWOMAN recipients so that no individuals or programs are identified. Please retain a copy of this study information for your future reference.

Thank you for participating in this survey.

SECTION A. PROFESSIONAL DEVELOPMENT

The first questions are about professional development opportunities offered to staff through WISEWOMAN funding since the beginning of the current funding cycle in September 2018.

A1. Does your program provide any professional development opportunities for any staff funded in part or full by WISEWOMAN (including internal staff, providers, and other contractors)?

Select one only

1  Yes

2  No GO TO B1

A2. Below is a list of broad topics that some WISEWOMAN recipients address through staff professional development. Since September 2018, how frequently has your program addressed each of the following topics through professional development, if at all?

Include professional development offered to any staff who are funded in part or full by WISEWOMAN such as internal staff, providers, and other contractors.

If trainings are available “on demand” (for example, web-based modules or other trainings that can be completed at staff members’ convenience), select the frequency with which staff are encouraged to access and complete the training.

	Select one per row
	Never	Less than once per year	1-2 times per year	More than 2 times per year
a. WISEWOMAN orientation and program basics (including current hypertension guidelines)	0 	1 	2 	3 
b. Identification of patients with hypertension	0 	1 	2 	3 
c. Proper clinical measurement technique	0 	1 	2 	3 
d. Protocols for medication adherence	0 	1 	2 	3 
e. Appropriate use of self-measured blood pressure monitoring protocols	0 	1 	2 	3 
f. Patient-centered risk reduction counseling	0 	1 	2 	3 
g. Motivational interviewing	0 	1 	2 	3 
h Health coaching	0 	1 	2 	3 
i. Team-based care	0 	1 	2 	3 
j. Health care models (such as patient-centered care, clinical systems design, and decision-supports)	0 	1 	2 	3 
k. Health literacy and use of plain language in interactions with patients	0 	1 	2 	3 
l. Cultural competence and sensitivity	0 	1 	2 	3 
m. Community health strategies to promote healthy behaviors	0 	1 	2 	3 
n. Patient navigation	0 	1 	2 	3 
o. Data quality and improvement techniques	0 	1 	2 	3 
p. Use of a WISEWOMAN database	0 	1 	2 	3 
q. Other professional development opportunities	0 	1 	2 	3 
Specify:
r. Other professional development opportunities	0 	1 	2 	3 
Specify:

A3. Thinking of the topics on which your program provides professional development, has your program offered any of the following types of professional development to WISEWOMAN staff since September 2018?

	Select one per row
	Yes	No
a. In-person trainings (led by internal staff)	1 	0 
b. In-person trainings (led by external/ hired staff)	1 	0 
c. Joint trainings with other organizations in the community	1 	0 
d. National and regional meetings (for example, on heart disease, public health, or other relevant topics)	1 	0 
e. Group trainings over the telephone/ webinars	1 	0 
f. Online training modules that can be accessed at staff members’ convenience	1 	0 
g. Other way(s) of conducting professional development	1 	0 
Specify:

A4. Since September 2018, which of the following groups of staff have been offered each type of professional development opportunity?

Please include any staff who are funded in part or full by WISEWOMAN such as internal staff, providers, and other contractors.

If your program has not offered one or more of the professional development opportunities listed since September 2018, leave the row(s) blank.

		Select all that apply per row
	Program director and manager	Data management staff	Evaluation staff	Other program staff	Lifestyle program staff	Health coaching (HC) staff	Clinical providers
a. In-person trainings (led by internal staff)	1 	2 	3 	4 	5 	6 	7 
b. In-person trainings (led by external/ hired staff)	1 	2 	3 	4 	5 	6 	7 
c. Joint trainings with other organizations in the community	1 	2 	3 	4 	5 	6 	7 
d. National and regional meetings	1 	2 	3 	4 	5 	6 	7 
e. Tele-conferences	1 	2 	3 	4 	5 	6 	7 
f. Online training modules that can be accessed at staff members’ convenience	1 	2 	3 	4 	5 	6 	7 
g. Other type of professional development not listed above	1 	2 	3 	4 	5 	6 	7 
Specify:

SECTION B. PARTNERSHIPS

The next questions are about your program’s strategic partnerships with:

• Organizations that provide clinical services, such as federally qualified health centers, public health departments, and other entities that provide WISEWOMAN screening services (referred to as “clinical provider sites”)

• Non-clinical organizations, such as state government agencies, community entities, and other organizations

Partnerships with Clinical Provider Sites

B1. How many clinical provider sites serve WISEWOMAN participants?

Count each unique site where WISEWOMAN screenings are conducted (including clinics, public health departments, and other locations that provide WISEWOMAN screening services).

TOTAL NUMBER OF SITES

B2. Approximately what percentage of clinical provider sites are part of Federally Qualified Health Centers (FQHCs)?

PERCENT OF SITES THAT ARE FQHCS

%

B3. Approximately what percentage of clinical provider sites primarily offer primary care services?

Include clinical provider sites that primarily provide primary care services and also provide some women’s health/ OBGYN services (such as pap smears).

PERCENT OF SITES PROVIDING PRIMARY CARE SERVICES

%

B4. What is the payment structure that your organization uses to pay for clinical services?

	Select one response per row
	Yes	No
a. Fee for service	1 	0 
b. Capitated per participant	1 	0 
c. Capitated by practice	1 	0 
d. Pay for performance	1 	0 
e. Bundled payment system	1 	0 
f. Don’t reimburse for clinical services	1 	0 
g. Other payment structure(s)	1 	0 
Specify:

B5. When does reimbursement for clinical services usually occur?

Select one only

1  Immediately after notification of the service delivery/submission of service data whether or not it is complete

2  A set amount of time after notification of service delivery/submission of data whether or not it is complete

3  After data are considered complete for a record

4  No set time period for reimbursement

5  Don’t reimburse for clinical services

Partnerships with non-clinical organizations

The next question is about the agreements that your program has with non-clinical organizations.

B6. Which of the following types of non-clinical partners does your program work with?

Include any partners with which you have formal or informal agreements.

	Select one response per row
	Yes	No
State/ Tribal Government Agencies
a. Diabetes Prevention Program	1 	0 
b. Heart Disease and Stroke Prevention Program	1 	0 
c. Tobacco Control program	1 	0 
d. Medicaid program	1 	0 
e. State/ Tribal Quitline program	1 	0 
f. Other types of state government agencies	1 	0 
Specify:
Community entities
g. Pharmacies	1 	0 
h. For-profit organizations (e.g., Take Off Pounds Sensibly (TOPS))	1 	0 
i. Non-profit organizations (e.g., YMCA)	1 	0 
j. Local government (such as town or municipal health departments)	1 	0 
k. Advocacy groups	1 	0 
l. Faith-based organizations	1 	0 
m. Local schools or universities	1 	0 
n. Other types of community entities	1 	0 
Specify:
Other entities
o. American Heart Association	1 	0 
p. Quality Improvement Organizations/Quality Improvement Networks (QIO/QIN)	1 	0 
q. Federal government agencies	1 	0 
r. Tribal nations	1 	0 
s. Other types of organizations	1 	0 
Specify:

SECTION C. PARTICIPANT RECRUITMENT

The next questions are about your program’s target population and recruitment strategies.

C1. To reduce disparities in cardiovascular health, does your program target any of the following populations?

	Select one response per row
	Yes	No
a. Rural and/or frontier populations	1 	0 
b. Specific racial/ ethnic groups	1 	0 
c. Specific cultural groups (e.g., LGBTQ groups or religious groups)	1 	0 
d. Women with disabilities	1 	0 
e. Medically underserved populations	1 	0 
g. Other populations	1 	0 
Specify:

C2. How does your program (including internal staff, providers and/or other contractors) recruit eligible participants?

	Select one response per row
	Yes	No
a. Review list of women enrolled in Breast and Cervical Cancer Early Detection Program (BCCEDP) and follow-up with eligible individuals	1 	0 
b. Referrals from clinical providers	1 	0 
c. Referrals from community-based resource providers	1 	0 
d. Outreach into the community	1 	0 
e. Traditional media outreach (such as radio or TV ads)	1 	0 
f. Social media outreach (such as Facebook or Instagram)	1 	0 
g. Other method(s) for identifying eligible participants	1 	0 
Specify:

C3. To recruit your program’s target populations, does your program use any of the following strategies?

	Select one response per row
	Yes	No
a. Partner with organizations that work closely with target populations	1 	0 
b. Hire bilingual or multicultural provider staff	1 	0 
c. Offer program materials in multiple languages	1 	0 
d. Other strategies	1 
Specify:

SECTION D. TEAM-BASED CARE

The next section is about your program’s use of team-based care to reduce cardiovascular disease risk with a focus on hypertension control and management.

D1. Approximately what percentage of your program’s clinical provider sites practice team-based care?

Team-based care is an intervention that incorporates a multidisciplinary team to improve the quality of cardiovascular-related care for patients. Team members provide process support and share responsibilities of care to complement the activities of the primary care provider.

Percent of sites practicing team-based care: %

IF NO CLINICAL PROVIDER SITES PRACTICE TEAM-BASED CARE, GO TO E1.

D2. What types of staff generally make up the health care delivery teams at your program’s WISEWOMAN provider sites?

Select all that apply

1  Patient

2  Physician(s)/ Primary care doctor

3  Nurse practitioner or Physician assistant (NP/PA)

4  Registered nurse or Licensed practical nurse (RN/LPN)

5  Medical assistant

6  Nutritionist/dietician

7  Lifestyle program coordinator

8  Health coach

9  Social worker(s)

10  Community health worker

11  Case manager

12  Pharmacist

13  Other staff

Specify:

14  Don’t know

D3. On average, how often do professionals on the health care delivery team at WISEWOMAN provider sites conduct the following activities?

	Select one per row
	Daily	Weekly	Bi-Weekly	Monthly	Less than monthly	Don’t Know
a. Team meetings with patient present	1 	2 	3 	4 	5 	d 
b. Team meetings without patient	1 	2 	3 	4 	5 	d 
c. Chart review/medical record review	1 	2 	3 	4 	5 	d 
d. Referrals to other services	1 	2 	3 	4 	5 	d 
e. Provide patient education on self-management	1 	2 	3 	4 	5 	d 
f. Provide support on medication management	1 	2 	3 	4 	5 	d 

D4. How do members of the health care delivery team at WISEWOMAN provider sites communicate about patients and coordinate care? Do they use…

	Select one response per row
	Yes	No	Don’t Know
a. A shared electronic health record (EHR) system	1 	0 	d 
b. Email or web-based communication	1 	0 	d 
c. Phone communication	1 	0 	d 
d. In-person communication	1 	0 	d 
e. Sharing or faxing of hardcopy materials	1 	0 	0 
f. Some other form(s) of communication	1 	0 	d 
Specify:

SECTION E. TRACKING AND MONITORING CLINICAL MEASURES

The next questions are about activities that your program uses to:

• Identify patients with uncontrolled hypertension

• Provide screening services

• Conduct risk reduction counseling

• Make and track clinical referrals for abnormal and alert screening values

• Encourage participants to return for annual rescreening visits

• Promote medication access

E1. Since September 2018, which of the following strategies has your program used to promote hypertension control among WISEWOMAN participants?

	Select one response per row
	Yes	No
a. Provided technical assistance to clinical provider sites on use of hypertension control protocols	1 	0 
b. Used Health IT reports to identify patients with uncontrolled hypertension	1 	0 
c. Used Health IT reports to identify patients who did not return for follow-up appointments for abnormal and alert blood pressure values	1 	0 
d. Partnered with healthy behavior support providers that share patients data with clinical provider sites (i.e., use bi-directional feedback mechanisms)	1 	0 
e. Purchased blood pressure monitors for participants to measure blood pressure at home	1 	0 
f. Trained clinical providers or other WISEWOMAN staff on self-measured blood pressure monitoring with clinical support	1 	0 
g. Referred participants to Medication Therapy Management (MTM) services	1 	0 
h. Other strategies	1 	0 
Specify:

E2. Of the clinical provider sites that serve WISEWOMAN participants, approximately what percentage currently use electronic health records (EHRs)?

An EHR is a digital version of a patient’s medical history that is maintained by the clinical provider. EHRs are often distinct from WISEWOMAN data systems used to collect data on program participants and submit data to CDC.

Percent of sites using EHRs:

%

IF NO SITES USE EHRs, GO TO E3

E3. Do the clinical provider sites that use electronic health records (EHRs) typically use EHRs for any of the following activities?

	Select one response per row
	Yes	No	Don’t Know
a. Tracking patient information	1 	0 	d 
b. Tracking referrals to clinical services	1 	0 	d 
c. Tracking referrals to heathy behavior support services (such as health coaching and lifestyle programs)	1 	0 	d 
d. Tracking attendance at healthy behavior support services (such as health coaching and lifestyle programs)	1 	0 	d 
e. Identifying participants who meet referral criteria for healthy behavior support services (such as health coaching and lifestyle programs)	1 	0 	d 
f. Communicating with other health and service providers about patients	1 	0 	d 
g. Monitoring clinical measures (such as high blood pressure)	1 	0 	d 
h. Identifying patients with uncontrolled hypertension	1 	0 	d 
i. Other activities	1 	0 	d 
Specify:

E4. Do clinical providers conduct WISEWOMAN screenings in any of the following settings?

	Select one response per row
	Yes	No
a. Traditional medical offices	1 	0 
b. In participants’ homes	1 	0 
c. Mobile clinics	1 	0 
d. Other locations	1 	0 
Specify:

E5. At most WISEWOMAN sites, who conducts risk reduction counseling with participants?

Select all that apply

1  Physician

2  Nurse practitioner or Physician Assistant (NP/PA)

3  Registered nurse or licensed practical nurse (RN/LPN)

3  Medical assistant

4  Health coach

99  Other staff

Specify:

E6. When participants are referred to clinical services based on screening results, are they offered any of the following case management or health navigation services to facilitate the referral?

	Select one response per row
	Yes	No
a. Appointment scheduling assistance	1 	0 
b. Transportation services (to and from appointments)	1 	0 
c. Child care	1 	0 
d. Translation services	1 	0 
e. Financial assistance	1 	0 
f. Enrollment in health insurance	1 	0 
g. Other type(s) of service	1 	0 
Specify:

E7. How do program staff such as clinical providers or other WISEWOMAN staff follow up with participants who are referred for clinical services based on alert/ abnormal screening results?

	Select one response per row
	Yes	No
a. Telephone call	1 	0 
b. Email	1 	0 
c. Text messaging	1 	0 
d. Video communication (e.g. Skype, FaceTime)	1 	0 
e. Mail	1 	0 
f. Face-to- face at WISEWOMAN site	1 	0 
g. Face-to-face at another location	1 	0 
h. Patient portal or secure messaging system	1 	0 
i. Other type(s) of follow-up not listed above	1 	0 
Specify:

E8. Does your program track any of the following metrics regarding clinical referrals for program participants based on WISEWOMAN screening results?

	Select one response per row
	Yes	No
a. Providers available for referrals	1 	0 
b. Number of referrals made	1 	0 
c. Number of referrals completed	1 	0 
d. Services provided during referrals	1 	0 
e. Diagnoses	1 	0 
f. Clinical outcomes	1 	0 
g. Other metric(s) for clinical referrals not listed above	1 	0 
Specify:

E9. Which of the following barriers make it difficult for program participants to complete clinical referrals for abnormal and alert values?

If participants do not experience any barriers, please select “no” for each item.

	Select one response per row
	Yes	No
a. Lack of time	1 	0 
b. Lack of insurance coverage	1 	0 
c. Lack of access to clinical providers who are sensitive to participants' beliefs and values	1 	0 
d. Lack of transportation	1 	0 
e. Lack of child care	1 	0 
f. Substance abuse	1 	0 
g. Depression or other mental health conditions	1 	0 
h. Domestic/ intimate partner violence	1 	0 
i. Language barriers	1 	0 
j. Long waits for appointments with clinical providers	1 	0 
k. Difficulty scheduling appointments with clinical providers	1 	0 
l. Inconvenient provider office hours	1 	0 
m. Other barriers not listed above	1 	0 
Specify:

E10. Does your program use any of the following methods to encourage participants’ attendance at rescreening visits every 12 to 18 months?

	Select one response per row
	Yes	No
a. Reminders by phone for participants who are due for a rescreening	1 	0 
b. Reminders by email for participants who are due for a rescreening	1 	0 
c. Reminders by text message for participants who are due for a rescreening	1 	0 
d. Provide incentives (e.g., coupons, prizes, gifts) to participants who return for a rescreening	1 	0 
e. Provide child care for participants	1 	0 
f. Provide transportation for participants	1 	0 
g. Other methods to encourage attendance at rescreening visits	1 	0 
Specify:

E11. Does your program use any of the following methods to engage participants between screening visits?

	Select one response per row
	Yes	No
a. Disseminate health education messaging	1 	0 
b. Use social media to engage participants	1 	0 
c. Use newsletters or other traditional media to engage participants	1 	0 
d. Use health coaches for ongoing communication with participants	1 	0 
e. Conduct other community events	1 	0 
Specify:
f. Other methods to engage participants between screening visits	1 	0 
Specify:

E12. Below is a list of strategies that some recipients use to ensure participants’ access to affordable medication. Since September 2018, which of these strategies has your program used?

	Select one response per row
	Yes	No
a. Require health care providers to assist women with accessing affordable medication	1 	0 
b. Provide staff orientation and training on useful sources/ avenues for affordable medication	1 	0 
c. Maintain a database of useful resources and websites for affordable medication that providers can use	1 	0 
d. Offer a forum for providers or social service agencies to share resources and tips on accessing affordable medication	1 	0 
e. Reimburse providers for services related to helping patients access medication, such as submitting applications to pharmaceutical companies	1 	0 
f. Follow-up with providers to obtain a description of the process that will be used to ensure medication access	1 	0 
g. Conduct periodic audits to determine if participants who need medication resources were linked to these services	1 	0 
h. Conduct periodic participant surveys that include questions about medication access	1 	0 
i. Other strategies to ensure participant access to affordable medication	1 	0 
Specify:

SECTION F. HEALTHY BEHAVIOR SUPPORT SERVICES

The next section is about the healthy behavior support services that your WISEWOMAN program provides to WISEWOMAN participants, including:

• Lifestyle programs (such as Weight Watchers, the National Diabetes Prevention Program, and other evidence-based programs)

• Health coaching

• Other community-based resource referrals

Lifestyle Programs

F1. Does your program use any of the following methods to support completion of lifestyle programs?

	Select one response per row
	Yes	No
a. Reminders by phone	1 	0 
b. Reminders by email	1 	0 
c. Reminders by text message	1 	0 
d. Provide incentives (e.g., coupons, prizes, gifts)	1 	0 
e. Provide child care for participants	1 	0 
f. Provide transportation for participants	1 	0 
g. Reimbursement of lifestyle program fees	1 	0 
h. Conduct lifestyle program sessions by phone, video, or webinar	1 	0 
i. Use social media to engage participants between lifestyle program sessions	1 	0 
j. Use community health workers to follow-up with participants	1 	0 
k. Other methods to facilitate completion lifestyle programs	1 	0 
Specify:

F2. How does your program track participation in lifestyle programs?

Select all that apply

1  Follow-up with lifestyle program providers

2  Follow-up with participants

3  Use of an integrated electronic tracking system

4  Other strategies

Specify:

Health Coaching

F3. How does your program provide health coaching for participants?

	Select one response per row
	Yes	No
a. Use WISEWOMAN funding to employ centralized health coaches	1 	0 
b. Contract with clinical provider sites to provide health coaching	1 	0 
c. Contract with a third-party organization to provide health coaching for WISEWOMAN participants	1 	0 
d. Use some other approach to provide health coaching	1 	0 
Specify:

F4. Does your program use any of the following methods to support completion of health coaching?

	Select one response per row
	Yes	No
a. Reminders by phone	1 	0 
b. Reminders by email	1 	0 
c. Reminders by text message	1 	0 
d. Provide incentives (such as coupons, prizes, and gifts)	1 	0 
e. Provide child care for participants	1 	0 
f. Provide transportation for participants	1 	0 
g. Conduct health coaching sessions by phone, video, or webinar	1 	0 
h. Use social media to engage participants between health coaching sessions	1 	0 
i. Other methods to facilitate completion of health coaching	1 	0 
Specify:

F5. How does your program track participation in health coaching?

Select all that apply

1  Information provided or submitted by health coaching providers

2  Follow-up with participants

3  Use of an integrated electronic tracking system

99  Other strategies

Specify:

Community Based Resources

F6. Since the beginning of the current funding cycle in September 2018, has your program referred participants to any of the following community-based resources?

Select all that apply

Physical Activity/Nutrition Resources

1  Recreation departments

2  Local parks

3  Walking/biking trails

4  Mall walking programs

5  Gardening programs

6  Food coupon programs

7  Farmers’ markets

8  Nutrition classes

Tobacco Cessation Resources

9  Quitline

10  Community-based tobacco cessation program

11  Translation services for quitlines

Other Resources

12  Mental health services

13  Job training

14  Translation services

15  Violence prevention services

16  Transportation services

17  Discount/free cost medication programs

18  Faith-based programs

99  Other

Specify:

98  Program has not made any community-based resource referrals this funding cycle

The next questions are about referrals to lifestyle programs, health coaching, AND other community-based resources.

F7. Which of the following types of staff make referrals to lifestyle programs, health coaching, and other community-based resources?

	Select one response per row
	Yes	No
a. Primary care doctor/ Physician	1 	0 
b. Nurse practitioner or Physician assistant (NP/PA)	1 	0 
c. Registered nurse or Licensed practical nurse (RN/LNP)	1 	0 
d. Medical assistant	1 	0 
e. Nutritionist/ dietician	1 	0 
f. Health educator	1 	0 
g. Social workers/case managers	1 	0 
h. Community health workers (Lay Health Workers/educators, community health advocates, community health outreach workers, Promotores y Promotoras de Salud)	1 	0 
i. Pharmacist	1 	0 
j. Other staff	1 	0 
Specify:

F8. Which of the following are challenges participants of your program face in completing referrals to lifestyle programs, health coaching, and other community-based resources?

	Select one response per row
	Yes	No
a. Lack of time	1 	0 
b. Lack of access to culturally appropriate services	1 	0 
c. Lack of transportation	1 	0 
d. Lack of child care	1 	0 
e. Substance abuse	1 	0 
f. Depression or other mental health conditions	1 	0 
g. Domestic/intimate partner violence	1 	0 
h. Language barriers	1 	0 
i. Inconvenient service hours	1 	0 
j. Lack of support from family and friends	1 	0 
k. Lack of interest in modifying health behaviors	1 	0 
l. Other barrier(s)	1 	0 
Specify:

SECTION G. MONITORING AND EVALUATION

The next section is about your program’s monitoring and evaluation efforts since the beginning of the current funding cycle in September 2018.

G1. How does your program use Minimum Data Element (MDE) data?

Select all that apply

1  Monitor outcomes of clinical services

2  Monitor outcomes of lifestyle programs and health coaching

3  Monitor outcomes of other community-based programs/services

4  Evaluate and measure program performance

5  Conduct data quality assurance

6  Prepare reports

7  Communicate program efforts and results to the CDC, the public, legislators, or other stakeholders

99  Other use of MDE data

Specify:

G2. Who is responsible for conducting evaluation activities for your WISEWOMAN program?

If your program uses both internal program staff and a contracted evaluator, select the individual who is primarily responsible for evaluation activities.

Select one only

1  Internal program staff

2  Contracted evaluator

3  Other

Specify:

G3. Which of the following evaluation methodologies does your program use?

An evaluation methodology defines the parameters and approach to answering research questions.

Select all that apply

1  Comparison group

2  Cross-sectional descriptive analysis

3  Longitudinal/time series design

4  Pre-post design

5  Trend analysis

99  Other method not listed above

Specify

G4. Since September 2018, which of the following has your program used to conduct evaluations?

	Select one response per row
	Yes	No
a. Minimum Data Elements (MDEs)	1 	0 
b. Program administrative data	1 	0 
c. Case studies	1 	0 
d. Interviews or surveys with stakeholders (such as participants, program staff, providers, and partners)	1 	0 
e. Other data sources	1 	0 
Specify:

G5. Since September 2018, in which of the following ways has your program shared evaluation findings with stakeholders and the public? Have you used…

If you do not share evaluation findings, please select “no” to all.

	Select one response per row
	Yes	No
a. Best practice toolkits?	1 	0 
b. Fact sheets?	1 	0 
c. Issue briefs?	1 	0 
d. Reports?	1 	0 
e. Journal articles?	1 	0 
f. Webinars?	1 	0 
g. Live presentations?	1 	0 
h. Infographics?	1 	0 
i. Other way(s) not listed above?	1 	0 
Specify:

G6. Since September 2018, has your program shared evaluation findings with any of the groups listed below?

If you do not share evaluation findings, please select “no” to all.

	Select one response per row
	Yes	No
a. Other recipients	1 	0 
b. Local policy makers	1 	0 
c. CDC	1 	0 
d. Other federal policy makers	1 	0 
e. Participants	1 	0 
f. Program staff	1 	0 
g. Partners	1 	0 
h. Other groups	1 	0 
Specify:

SECTION H. ADDITIONAL FEEDBACK

H1. Is there anything else you would like to share about your WISEWOMAN program?

Thank you for taking the time to complete the survey!

Please return the completed pdf to [email protected].