Summary of Respondents and Conversion for Annualization

Attachment 3e: Crosswalk of Type and Number of Respondents (total and annualized), by Evaluation Component and Information Collection Instrument

DP18-1815PHHF18

Improving the Health of Americans through Prevention and Management of Diabetes and Heart Disease and Stroke

Category A: DIABETES MANAGEMENT AND TYPE 2 DIABETES PREVENTION

This cell = 1 if the form will be completed 1 time during the 3-year clearance period

This cell = 2 if the form will be completed 2 times during the 3-year clearance period

This cell = 3 if the form will be completed 3 times (i.e., annually) during the 3-year clearance period

No. sampled x Total Times / 3 = This cell

Type of Respondents (and Sampling Frame)	Form Name	No. in Respondent Universe	Total No. to be sampled	Total No. of Times the Form will be Completed over the 3-year clearance period	Annualized Number of Respondents
Category A Rapid Partner Site-Level Evaluations
HD recipient staff (HD recipient Staff)	Att. 4a: DSMES Partner Site Level Rapid Evaluation Nomination Form	51	51	1	17
	Att. 4b: National DPP Partner Site Level Rapid Evaluation Nomination Form	51	51	1	17
DSMES partner site staff (DSMES Site Staff)	Att. 4c: DSMES Rapid Evaluation Survey Questionnaire	Unknown	510	2	340
DSMES partner site staff (DSMES Site Staff - Healthcare Social Worker)	Att. 4d: DSMES Rapid Evaluation Interview Guide - Program Coordinator	Unknown	14	3	14
DSMES partner site staff (DSMES Professionals - Pharmacists, RNs, RDs)	Att. 4e: DSMES Rapid Evaluation Interview Guide - Professional	Unknown	28	3	28
DSMES partner site staff (DSMES Paraprofessionals - CHWs, Medical Assistants, Diabetes and Pharmacy Technicians)	Att. 4f: DSMES Rapid Evaluation Interview Guide - Paraprofessional	Unknown	28	3	28
National DPP partner site staff (National DPP Sites)	Att. 4g: National DPP Rapid Evaluation Survey Questionnaire	Unknown	510	2	340
National DPP partner site staff (National DPP Program Coordinators)	Att. 4h: National DPP Rapid Evaluation Interview Guide - Program Coordinator	Unknown	14	3	14
National DPP partner site staff (National DPP Lifestyle Coaches)	Att. 4i: National DPP Rapid Evaluation Interview Guide - Lifestyle Coach	Unknown	28	3	28
1815 Recipient-Led Evaluation Reporting Deliverables
HD recipient staff (HD Recipient Staff)	Att. 5a: Category A EPMP Template	51	51	1	17
	Att. 5b: Category A - DDT Recipient-led Annual Evaluation Report Template	51	51	3	51
Total
			1,336 respondents to be sampled		894 annualized number of respondents

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