G5 Key Informant Interviews with Champions

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Key Informant Interviews with Champions (Semi-Structured Interview via Phone)

You are invited to participate in this interview because you have been a champion for the Nursing Workgroup for the CDC FASD Project. The purpose of this interview is to discuss your activities related to FASD prevention or alcohol SBI promotion. The interview will take approximately 45 minutes to complete. Your participation is voluntary and responses will be kept secure. There are no costs associated with participating nor will you directly benefit from participation.

1. As a nursing champion for FASD prevention and/or alcohol SBI promotion, what kinds of activities have you undertaken or been involved in (optional: in the past year)?

Optional Probes (use as needed):

1. Can you tell me any more about advocacy activities in particular?

   1. Have you advocated with local, state, or national policymakers?

2. Can you tell me any more about dissemination activities in particular?

   1. Can you tell me about any messaging strategies?

3. Were there any training activities you either attended or conducted?

   1. Have you incorporated FASD or alcohol SBI content into training or presentations within your organization? Outside of your organization?

4. Were there any other activities that served your profession (i.e., specific to nurses, including nursing organizations and nursing conferences)?

5. Were there any other activities within organizations (i.e. healthcare provider organizations that might include disciplines besides nursing)?

2. What was the reach of these activities?

Optional Probes (use as needed):

1. About how many individuals did you advocate with/message/train/etc?

3. Which activities were most successful?

   1. In your opinion, what was the specific impact of each activity and for whom?

4. Which activities were less successful?

   1. What aspects were most challenging?

   2. What suggestions do you have for modifying the approach in the future?

5. How do you see your role as a nurse champion (for FASD prevention and/or alcohol SBI promotion) over the next year?

   1. What goals do you have?

   2. How can we and our partners support work toward those goals?

CDC estimates the average public reporting burden for this collection of information as 45 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 this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS

D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).