0920- Attachment 5: Instrument: Subrecipient Survey

Form Approved

OMB NO: 0920-xxxx

Exp. Date: X/XX/XXXX

Public reporting burden of this collection of information is estimated at 30 mins per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/Information Collection Review Office, 1600 Clifton Road, NE, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-xxxx).

Attachment 5: Instrument: Subrecipient Survey

Welcome to the Coordinated Community Response Team Survey!

This survey has been sent to you as the point of contact on the Coordinated Community Response Team participating in a program or policy effort as part of the CDC DELTA Impact program. You may complete the survey with any other CCR staff that you think would be appropriate. Please submit only ONE survey per CCR. This survey is an opportunity for CDC to hear feedback from the implementing agencies. We greatly appreciate your perspective and your input will be used to inform future initiatives. The results of the CCR surveys will be shared only in aggregate. Your individual responses will not be shared with the State Coalition staff or anyone outside of the CDC.

Coalition refers to your State Domestic Violence Coalition (SDVC).

Primary Prevention refers to activities and strategies that keep intimate partner violence (IPV) or domestic violence (DV) from first occurring.

Community and Societal Level Primary Prevention (CSPP) refers to prevention strategies that are designed to impact characteristics of the settings (e.g., school, workplace, and neighborhood) in which social relationships occur, or social and physical environment factors. This is different from individual level strategies (usually designed to promote attitudes, beliefs, skills, and behaviors) and relationship level strategies (focused on relationships that influence an individual behavior and experience).

Program or Policy Effort (PPE)– refers to the evidence informed program or policy effort being implemented by your agency or Coordinated Community Response Team. The PPE will fall in one of the following focus areas: create protective environments, engage influential adults and peers, or strengthen economic supports or families.

It should take approximately 30 minutes to complete this survey.

CDC estimates the average public reporting burden for this collection of information as 30 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 (#).

In what state is your CCR?_________

Is your CCR implementing more than one DELTA Impact funded PPE?

• Yes, we are implementing TWO PPEs.

• No, just one PPE.

If your CCR is implementing more than one PPE, please answer the following questions about one PPE. You will then be asked the same set of questions about the second PPE.

What is the name of this DELTA Impact funded program or policy effort? ______________

Delta Impact Program or Policy Effort Implementation

Please answer the following questions about the DELTA impact program or policy effort (PPE) being implemented by your organization.

	Not at all	Minimally	Somewhat	To a Great Extent	N/A
To what extent is the PPE meeting the key milestones as laid out in the implementation plan?
To what extent is the PPE reaching the intended setting(s) and populations?
To what extent is the PPE succeeding in addressing the intended risk and protective factors?
To what extent, did your organization develop new partnerships with local organizations doing IPV related work as a result of DELTA Impact?

What is the likelihood that the program or policy effort can continue after the DELTA Impact project period ends (March 2023)?

• Very unlikely

• Somewhat unlikely

• Somewhat likely

• Very Likely

• N/A Unable to Assess

What is the likelihood that the CCR could expand or scale up the program or policy effort (e.g. expand to additional settings or scale up to reach more individuals in existing settings) beyond what was originally planned?

• Very unlikely

• Somewhat unlikely

• Somewhat likely

• Very Likely

• N/A Unable to Assess

What were the most challenging aspects of implementing the PPE?

What resources were most helpful to the implementation of the PPE?

Please note the MAIN challenge your CCR may face to sustain the PPE after the project period.

Coalition Involvement and Support with PPE

Please rate the State Domestic Violence Coalition’s involvement in the planning, implementation, and evaluation of the program or policy effort being implemented by your CCR.

Please rate the Coalition’s involvement in the following activities:
	1 None	2 Minimal	3 Moderate	4 High	N/A Unable to Assess
In the development of the PPE Implementation plan
In the development of the PPE Evaluation plan
In updating the PPE Implementation plan as needed
In updating the PPE Evaluation Plan as needed
In analysis or interpretation of the PPE evaluation results
In communication about the PPE implementation and evaluation to partners

Please share any additional feedback regarding the Coalition’s involvement in the planning, implementation, and evaluation of the program or policy effort.

Are you implementing a second PPE?

Yes – Will answer same questions for second PPE

No – Will skip to question #3-#22)

CCR Staff Knowledge and Skills Related to Community and Societal Primary Prevention (CSPP) Efforts

Please consider the CCR staff’s general knowledge and skills related to community and societal level primary prevention (CSPP) strategies BEFORE the DELTA Impact (DI) project period began in 2018 and CURRENTLY, in the fourth year of the project period.

Please rank the following from the 1) lowest level (e.g. no awareness, knowledge, or capacity) to 4) the highest level (e.g. very knowledgeable, skilled, or capable) for BEFORE DI and CURRENTLY.

		1 None	2 Some	3 Moderate	4 Proficient	N/A
Knowledge about community and societal level strategies to prevent IPV	BEFORE DI
	CURRENTLY
Capacity to implement a community and societal level primary prevention program or policy effort.	BEFORE DI
	CURRENTLY
Capacity to evaluate a community and societal level primary prevention program or policy effort.	BEFORE DI
	CURRENTLY
Awareness of available data sources related to community and societal level primary prevention and IPV.	BEFORE DI
	CURRENTLY

CCR Support of & Resources Devoted to CSPP

Please consider the support for community and societal level primary prevention (CSPP) strategies at your organization BEFORE the DELTA Impact (DI) project period began in 2018 and CURRENTLY, in the fourth year of the project period.

Please rank the following from the 1) lowest amount (e.g. no support or resources) to 4) the highest amount (e.g. a lot of support or resources) for BEFORE DI and CURRENTLY

		1 None at all	2 A Little	3 A Moderate Amount	4 A Great Deal	N/A
Support for community and societal level primary prevention strategies among CCR staff.	BEFORE DI
	CURRENTLY
Support for community and societal level primary prevention strategies among CCR leadership	BEFORE DI
	CURRENTLY
Financial resources devoted to community and societal level primary prevention efforts above and beyond funding dedicated to the specific DELTA Impact program or policy efforts	BEFORE DI
	CURRENTLY
Non-financial resources (training, informational materials, webinars, etc.) devoted to community and societal level primary prevention efforts.	BEFORE DI
	CURRENTLY

Please share any additional comments about how support for community and societal level prevention efforts at your organization has changed since before DELTA Impact.

Coalition Support

Please rank your agreement with the following statements about the training, technical assistance, and support provided by the State Domestic Violence Coalition to the CCR.

	1 Strongly Disagree	2 Somewhat Disagree	3 Somewhat Agree	4 Strongly Agree	N/A Unable to Assess
I am satisfied with the amount of learning opportunities the Coalition facilitated or shared on implementing community and societal level primary prevention program or policy efforts.
I am satisfied with the amount of training or learning opportunities the Coalition facilitated or shared on evaluating community and societal level primary prevention program or policy efforts.
I am satisfied with the technical assistance our CCR received from the Coalition.
I am satisfied with how the Coalition responded to our questions and concerns throughout the project period.

What types of support from the Coalition was most helpful in implementing and evaluating the PPE(s)?

What additional type of support from the Coalition would have facilitated implementation and evaluation of the PPE(s):

Thank you for your participation!

Is there anything else you would like to share with us about your participation in DELTA Impact in general?

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