Form 0920-0841 NCCCP Survey

Form Approved

OMB # 0920-0841

Expiration Date MM/DD/YYYY

ATTACHMENT 2e

Data Collection Instrument_DP22-2202 NCCCP Survey

Thank you for participating in this assessment!

The Centers for Disease Control and Prevention’s (CDC) Division of Cancer Prevention and Control (DCPC) funds the National Comprehensive Cancer Control Program (NCCCP DP22-2202). Recipients have been tasked with implementing a program to support cancer coalition efforts that leverage resources to plan and implement evidence-based strategies. These strategies promote the primary prevention of cancer, support cancer early detection efforts, address the needs of survivors, and promote health equity. DCPC is interested in assessing NCCCP DP22-2202 recipients’ 1) Participant Characteristics; 2) Comprehensive Cancer Control (CCC) Plan; 3) EBIs and their responsiveness to the CCC Plan Priorities; 4) CCC Partnerships contributions to the CCC Plan Priorities Implementation and 5) program accomplishments. This assessment is being administered to program directors of NCCCP recipients and a designated external partner. The findings from the assessment will be used to identify how CDC can make program improvements. Dissemination of findings will help CDC staff, CDC leadership, recipients, and broader public health audiences understand lessons learned and recommendations for future programs. 

Please respond to the questions according to your individual experience. We expect this assessment to take approximately 45 minutes to complete. Your responses to this assessment will be stored and maintained in REDCap. The data collected in this assessment does not involve collection of sensitive and/or personally identifiable information; this assessment only collects information about the state, territorial, or tribal program, not personal information. Completion of this assessment is voluntary.

If you have any questions about this assessment, please contact Angela Moore at [email protected] or 770-488-3094.

Section 1: Participant characteristics

The purpose of the questions in this section is to collect information on your jurisdiction, current role within the program, tenure in the role, and chronic disease experience.

1. Please select your state, tribal, territory, or local jurisdiction from the list below.

[PLEASE SELECT ONE]

• Alabama Department of Public Health

• Alaska Cancer Prevention and Control Program

• Alaska Native Tribal Health Consortium

• American Indian Cancer Foundation

• American Samoa Department of Health

• Arizona Department of Health Services

• Arkansas Department of Health

• California Department of Public Health

• Cherokee Nation

• Colorado Department of Public Health and Environment

• Commonwealth of The Northern Mariana Islands

• Connecticut Department of Public Health

• Delaware Division of Public Health

• District of Columbia Department of Health

• Federated States of Micronesia Department of Education

• Florida Department of Health

• Fond Du Lac Reservation

• Georgia Department of Human Resources

• Great Plains Tribal Leaders Health Board

• Guam Department of Public Health

• Hawaii State Department of Health

• Idaho Department of Health and Welfare

• Illinois Department of Health

• Indiana State Department of Health

• Iowa Department of Public Health

• Kansas Department of Health and Environment

• Louisiana State University Health Sciences Center (LSUHSC) School of Public Health

• Maine CDC Division of Public health

• Maine Department of Health

• Marshall Islands Ministry of Health

• Maryland Department of Health and Mental Hygiene

• Massachusetts Department of Health

• Michigan Department of Community Health

• Minnesota Department of Health

• Mississippi Department of Health

• Montana Department of Public Health and Human Services

• Nebraska Department of Health and Human Services

• Nevada State Department of Public and Behavioral Health

• New Hampshire Department of Health and Human Services

• New Jersey Department of Health

• New Mexico Department of Health

• New York State Department of Health

• North Carolina Department of Health

• North Dakota Department of Health

• Northwest Portland Area Indian Health Board

• Ohio Department of Health

• Oklahoma State Department of Health

• Oregon Health Authority Public Health Division

• Pennsylvania Department of Health

• Republic of Palau Ministry of Health

• Rhode Island Department of Health

• South Carolina Department of Health

• South Dakota Department of Health

• South Puget Intertribal Planning Agency

• State of Missouri Department of Health

• Tennessee Department of Health

• Texas Department of State Health Services

• University of Kentucky

• University of Puerto Rico Comprehensive Cancer Center

• Utah State Department of Health

• Vermont Department of Health

• Virginia Department of Health

• Virgin Islands Department of Health Group

• Washington State Department of Health

• West Virginia Division of Health Promotion & Chronic Disease

• Wisconsin Comprehensive Cancer Control

• Wyoming Department of Health

• OTHER: [INSERT TEXT]
  
  
  

2. What is your primary role?

[PLEASE SELECT ONE]

• Program Director

• Program Coordinator/Program Manager

• Evaluator

• Policy Analyst

• Program Partner

• IF SELECTED:

2a. Type the name of the organization you are representing: [INSERT TEXT]

2b. Please select what sector best represents your organization:

[PLEASE SELECT ONE]

• Government Organization

• Non-profit Organization

• Academia/Education Organization

  • HBCU

  • Tribal Colleges and Universities

• Health Care Organization

• Coalition/Alliance Organization

• Community Based Organization

• Public Health Organization

• Organization representing Priority Population

• Business/For Profit/Consultant

• Professional Association

• Community Health Center

• Advocacy Group

• Health Insurance Company

• Foundation/Philanthropic

• Individual

• Faith Based Organization

• Public Relations/Media

• Minority Health Office

• Cultural/Ethnic Organization

• Elected/Appointed Official

• Environmental Organization

• Development/Planning Agency

• Parks and Recreation Organization

• Community Member

• Civic Organization

• Transportation Agency

• Agriculture Organization

• OTHER: [INSERT TEXT]

• OTHER: [INSERT TEXT]

[SKIP PATTERN: If ‘Program Partner’ is selected in Q2, skip down to Q25]

3. How long have you been in your current role?

[PLEASE SELECT ONE]

• Less than three years

• 3-5 Years

• 6-10 Years

• Over 10 Years
  
  
  

4. How long have you been working in chronic disease?

[PLEASE SELECT ONE]

• Less than three years

• 3-5 Years

• 6-10 Years

• Over 10 Years
  
  
  

5. Are you a member of a CCC coalition?

[PLEASE SELECT ONE]

• Yes

  • IF SELECTED:

5a. What best describes your position in the coalition?

• Leadership member

• Workgroup member

  • IF SELECTED:

5a.1. Please list the workgroups you are a member of: [INSERT TEXT]

• Member organization representative

• Other: [INSERT TEXT]

• No
  
  

1. Please type the name of your Partnership/Coalition:

   • [INSERT TEXT]
     
     

2. Is this Partnership/Coalition part of a 501(c) organization?

   • Yes

   • No
     
     

3. Is this Partnership/Coalition legislatively mandated?

   • Yes

   • No
     
     

4. Members in your Partnership/Coalition include the following:

[PLEASE SELECT ALL THAT APPLY]

• CDC Chronic Disease Programs

• Other Public Health Programs

• Other Government Entities

• Professional Association/Organization

• Academic/Medical Institutions

• Business/Industry

• Political Leaders

• Community-Based Organizations

• Community Members

• Survivors/Caregivers

• OTHER: [INSERT TEXT]
  
  

1. Does your Partnership/Coalition have workgroups or subcommittees?

   • Yes

     • If selected:

10a. Select all that apply:

• Prevention

• Screening

• Survivorship

• Evaluation

• Communication

• Policy

• Health Equity

• OTHER: [INSERT TEXT]

• No
  
  

1. Please select how large your Partnership/Coalition is:

• Less than 50 individuals

• 50 – 100 individuals

• More than 100 individuals
  
  

12. Please indicate which of these groups are important components of your population:

[SELECT ALL THAT APPLY]

For example:

• Which of the major racial/ethnic minority groups are present in your state/area (prevalence> 2%)?  Optional: You may also list special populations, even if their prevalence is not equal to 2% (e.g., immigrants). 

• Do you have significant urban and or/rural populations?

For those groups selected, please select if there is at least one member organization in your Partnership/Coalition that officially represents the group below.

• American Indian or Alaska Native

• Asian

• Black or African American

• Hispanic or Latino

• Native Hawaiian or Other Pacific Islander

• White

• Rural

• Urban

• Frontier

• Faith Based

• People with disabilities

• LGBTQ+

• OTHER: [INSERT TEXT]

[For each answer selected in Q12, the following question will be asked:]

12a. Is there at least one member organization in your Partnership/Coalition that officially represents this group?

• Yes

• No
  
  

Section 2: CCC Plan

The purpose of the questions in the next sections is to understand to what extent is the CCC plan implementation effective and to what extent do workplan strategies address CCC plan priorities.

CCC program priorities fall under four priority areas:

1. Promote the Primary Prevention of Cancer

2. Support Cancer Early Detection Efforts

3. Address the Needs of Cancer Survivors

4. Promote Health Equity

Definitions:
Comprehensive Cancer Control (CCC) Plan Priority - Goal, associated objectives, and strategies in a jurisdiction-specific (state, tribe, PIJ, territory) plan that has been selected for implementation

13. Select the topic below that associated with your CCC plan priorities:

[SELECT ALL THAT APPLY]

• Alcohol

• Breast Cancer

• Cervical Cancer

• Colorectal Cancer

• Health Equity

• Hepatitis and Liver Cancer Prevention

• Hereditary (Genetic) Cancer Syndromes

• Human Papillomavirus (HPV) Vaccination

• Lung Cancer

• Nutrition, Obesity and Physical Activity

• Radon

• Sun Safety and Overexposure to UV Rays/Skin Cancer

• Survivorship

• Tobacco Control

• OTHER: [INSERT TEXT]
  
  
  

[For each topic selected in Q12, the following questions will be asked:]

13a. How did your program identify this priority for your CCC plan?

• Examining burden data

• Examining risk factor data

• Existing partnership(s)

• Coalition consensus

• Program Champion

• Emerging issue as identified by national leaders

• Based on resources

• Social/political Environment

• OTHER: [INSERT TEXT]
  
  
  

13b. How did your program address this CCC plan priority? (e.g., convene coalition workgroup, partner with a coalition member, identify evidenced based intervention to implement in annual workplan, etc.)

• [INSERT TEXT]
  
  
  

13c. How long is the implementation for this priority?

• Less than a year

• 1-2 years

• 3-4 years

• Up to 5 years
  
  
  

13d. When do you know when a priority is fully addressed?

• Established benchmark is achieved

• Policy changes

• Reduction in cancer rates

• Reallocation of resources to other areas

• OTHER: [INSERT TEXT]
  
  
  

Section 3: EBIs and their responsiveness to CCC Plan Priorities

The purpose of the questions in the next sections is to understand to what extent are EBIs being successfully implemented to aid the achievement of CCC plan goals.

14. The following statements relate to your knowledge, abilities, and skills in selecting, adapting, implementing, and evaluating EBIs for each priority area – (1) Addressing primary prevention, (2) Supporting early detection; (3) Addressing needs of cancer survivors (4) Reducing cancer disparities and increasing health equity.

Please choose your level of expertise for the following:

	Novice	Advance Novice	Competent	Proficient	Expert
Knowledge to select EBIs for each priority area.
Knowledge to adapt EBIs for each priority area.
Knowledge to implement EBIs for each priority area.
Knowledge to evaluate EBIs for each priority area.
Ability to select EBIs for each priority area.
Ability to adapt EBIs for each priority area.
Ability to implement EBIs for each priority area.
Ability to evaluate EBIs for each priority area.
Skills to select EBIs for each priority area.
Skills to adapt EBIs for each priority area.
Skills to implement EBIs for each priority area.
Skills to evaluate EBIs for each priority area.

15. In which priority area have you had the most success in implementing EBIs? [SELECT ONE]

• Addressing primary prevention

• Supporting early detection

• Addressing needs of cancer survivors

• Reducing cancer disparities and increasing health equity

15a. In 1-2 sentences, please describe the nature of this success. It could be a process you used or an especially successful intervention in terms of an outcome achieved.

• [INSERT TEXT]
  
  
  

16. In which priority area have you had the biggest challenge in implementing EBIs? [SELECT ONE]

• Addressing primary prevention

• Supporting early detection

• Addressing needs of cancer survivors

• Reducing cancer disparities and increasing health equity
  
  
  

16a. In 1-2 sentences, please describe the nature of this challenge and what lessons you learned from this experience (i.e., what would you do differently if you had the chance to do it again).

• [INSERT TEXT]

17. Thinking of the last 2 years, can you select the EBIs that you have implemented during that time?

Alcohol [ANSWERS IN DROPDOWN]

• Dram Shop Liability

• Electronic Screening and Brief Intervention

• Enhanced Enforcement of Laws Prohibiting Sales to Minors

• Increasing Alcohol Taxes

• Maintaining Limits on Days of Sale

• Maintaining Limits on Hours of Sale

• Overservice Law enforcement Initiatives

• Privatizing of Retail Alcohol Sales

• Regulation of Alcohol Density

• Responsible Beverage Service Training

• OTHER: [INSERT TEXT]
  
  
  

Breast Cancer [ANSWERS IN DROPDOWN]

Increasing Cancer Screening

• Interventions Engaging Community Health Workers

• Multicomponent Interventions

• Patient Navigation Services

Client-Oriented Interventions

• Client Incentives

• Client Reminders

• Group Education

• Mass Media

• One-on-One Education

• Reducing Client Out-of-Pocket Costs

• Reducing Structural Barriers

• Small Media

Provider-Oriented Interventions

• Provider Assessment and Feedback

• Provider Assessment and Feedback

• Provider Reminder and Recall System

• OTHER: [INSERT TEXT]

Cervical Cancer [ANSWERS IN DROPDOWN]

Increasing Cancer Screening

• Interventions Engaging Community Health Workers

• Multicomponent Interventions

• Patient Navigation Services

Client-Oriented Interventions

• Client Incentives

• Client Reminders

• Group Education

• Mass Media

• One-on-One Education

• Reducing Client Out-of-Pocket Costs

• Reducing Structural Barriers

• Small Media

Provider-Oriented Interventions

• Provider Assessment and Feedback

• Provider Assessment and Feedback

• Provider Reminder and Recall System

• OTHER: [INSERT TEXT]
  
  
  

Colorectal Cancer [ANSWERS IN DROPDOWN]

Increasing Cancer Screening

• Interventions Engaging Community Health Workers

• Multicomponent Interventions

• Patient Navigation Services

Client-Oriented Interventions

• Client Incentives

• Client Reminders

• Group Education

• Mass Media

• One-on-One Education

• Reducing Client Out-of-Pocket Costs

• Reducing Structural Barriers

• Small Media

Provider-Oriented Interventions

• Provider Assessment and Feedback

• Provider Assessment and Feedback

• Provider Reminder and Recall System

• OTHER: [INSERT TEXT]

Hepatitis and Liver Cancer Prevention [ANSWERS IN DROPDOWN]

Enhancing Access to Vaccination Services

• Home visits to increase vaccination rates

• Reducing Client out-of-pocket costs

• Vaccination programs in schools and organized childcare centers

• Vaccination programs in WIC settings

Increasing Community Demand for Vaccinations

• Client-Held paper immunization records

• Client or family incentive rewards

• Client reminder and recall systems

• Clinic-based education when used alone

• Community-based interventions implemented in combination

• Community-wide education when used alone

• Monetary sanction policies

• Vaccination requirements for childcare, school, and college attendance

Provider- or System-Based Interventions

• Healthcare system-based interventions implements in combination

• Immunization information systems

• Provider assessment and feedback

• Provider education when used alone

• Providers reminders

• Standing orders

• OTHER: [INSERT TEXT]

Hereditary (Genetic) Cancer Syndromes [ANSWERS IN DROPDOWN]

• Breast Cancer Risk & Genetic Testing

• Improving Knowledge, Risk Perception, and Risk Communication Among Colorectal Adenoma Patients

• OTHER: [INSERT TEXT]
  
  
  

Human Papillomavirus (HPV) Vaccination [ANSWERS IN DROPDOWN]

Enhancing Access to Vaccination Services

• Home visits to increase vaccination rates

• Reducing Client out-of-pocket costs

• Vaccination programs in schools and organized childcare centers

• Vaccination programs in WIC settings

Increasing Community Demand for Vaccinations

• Client-Held paper immunization records

• Client or family incentive rewards

• Client reminder and recall systems

• Clinic-based education when used alone

• Community-based interventions implemented in combination

• Community-wide education when used alone

• Monetary sanction policies

• Vaccination requirements for childcare, school, and college attendance

Provider- or System-Based Interventions

• Healthcare system-based interventions implements in combination

• Immunization information systems

• Provider assessment and feedback

• Provider education when used alone

• Providers reminders

• Standing orders

• OTHER: [INSERT TEXT]

Lung Cancer [ANSWERS IN DROPDOWN]

Increasing Cancer Screening

• Interventions Engaging Community Health Workers

• Multicomponent Interventions

• Patient Navigation Services

Client-Oriented Interventions

• Client Incentives

• Client Reminders

• Group Education

• Mass Media

• One-on-One Education

• Reducing Client Out-of-Pocket Costs

• Reducing Structural Barriers

• Small Media

Provider-Oriented Interventions

• Provider Assessment and Feedback

• Provider Assessment and Feedback

• Provider Reminder and Recall System

• OTHER: [INSERT TEXT]

Nutrition, Obesity and Physical Activity [ANSWERS IN DROPDOWN]

Interventions to Promote Good Nutrition

• Community-based Digital Health and Telephone Interventions to Increase Healthy Eating and Physical Activity

• Digital Health and Telephone Interventions to Increase Healthy Eating and Physical Activity Among Students at Institutions of Higher Education

• Gardening Interventions to Increase Vegetable Consumption Among Children

• Home-delivered and Congregate Meal Services for Older Adults

• Worksite Digital Health and Telephone Interventions to Increase Healthy Eating and Physical Activity

Interventions to Increase Physical Activity - Behavioral and Social Approaches

• Classroom-based Physical Activity Break Interventions

• Classroom-based Physically Active Lesson Interventions

• Digital Health Interventions for Adults 55 Years and Older

• Enhanced School-Based Physical Education

• Family-Based Interventions

• Home-based Exercise Interventions for Adults Aged 65 years and Older

• Individually Adapted Health Behavior Change Programs

• Interventions Including Activity Monitors for Adults with Overweight or Obesity

• Social Support Interventions in Community Settings

Interventions to Increase Physical Activity - Social Support Interventions in Community Settings

• Community-Wide Campaigns

• Stand-Alone Mass Media Campaigns

Interventions to Increase Physical Activity - Environmental and Policy Approaches

• Built Environment Approaches Combining Transportation System Interventions with Land Use and Environmental Design

• Creating or Improving Places for Physical Activity

• Interventions to Increase Active Travel to School

• Park, Trail, and Greenway Infrastructure Interventions when Combined with Additional Interventions

• Park, Trail, and Greenway Infrastructure Interventions when Implemented Alone

• Point-of-Decision Prompts to Encourage Use of Stairs

• OTHER: [INSERT TEXT]
  
  
  

Radon [ANSWERS IN DROPDOWN]

• Ask your patients if they have tested their home for radon. If they have not, inform them about the health risk posed by radon and urge them to test their home for radon.

• Add radon testing questions to the routine electronic medical record questionnaire.

• Team up with the Centers for Disease Control and Prevention (CDC)-funded comprehensive cancer control program in your state. These programs have aligned the priorities, goals, and activities of cancer coalitions with practices that reduce radon-induced lung cancer: https://www.cdc.gov/cancer/ncccp/ccc_plans.htm.

• Provide information in your offices and clinics that promotes radon testing and mitigation; information can be obtained from the following sources:

• Iowa Cancer Consortium—www.canceriowa.org/breathingeasier

• Online learning and action network—www.radonleaders.org

• EPA—www.epa.gov/radon

• CDC—www.cdc.gov/radon

• State radon offices—www.epa.gov/radon/find-information-about-local-radon-zones-and-state-contact-information

• The USPSTF recommends annual LDCT screening for lung cancer in adults ages 55 to 80 who have a 30-pack-year smoking history and currently smoke or have quit within the past 15 years. For individuals who do not have lung cancer or do not qualify for screening, interviews for LDCT screening eligibility represent teachable moments to discuss efforts to reduce lung cancer risk, such as testing their homes for radon.

• Share information about the health risks of protracted radon exposure with other health care providers. For example, encourage your colleagues to participate in the discussion forums at www.radonleaders.org, where they can learn about the experiences of other health care providers regarding radon and find links to the research that provides the scientific foundation for radon risk estimates

• OTHER: [INSERT TEXT]
  
  
  

Sun Safety and Overexposure to UV Rays/Skin Cancer [ANSWERS IN DROPDOWN]
Increasing Cancer Screening

• Interventions Engaging Community Health Workers

• Multicomponent Interventions

• Patient Navigation Services

Client-Oriented Interventions

• Client Incentives

• Client Reminders

• Group Education

• Mass Media

• One-on-One Education

• Reducing Client Out-of-Pocket Costs

• Reducing Structural Barriers

• Small Media

Provider-Oriented Interventions

• Provider Assessment and Feedback

• Provider Assessment and Feedback

• Provider Reminder and Recall System

Preventing Skin Cancer – Community wide interventions

• Mass Media

• Multicomponent Community-Wide Interventions

Preventing Skin Cancer – Education and Policy Approaches

• Child Care Center-Based Interventions

• High School- and College-Based Interventions

• Interventions in Outdoor Occupational Settings

• Interventions in Outdoor Recreational and Tourism Settings

• Primary and Middle School-Based Interventions

• OTHER: [INSERT TEXT]
  
  
  

Survivorship [ANSWERS IN DROPDOWN]

• Alleviating Depression Among Patients with Cancer (ADAPt-C)

• BrainHQ

• Breast Cancer Education Intervention (BCEI)

• Bright IDEAS: Problem-Solving Skills Training

• Coping with Chemotherapy

• Dyadic Support for Men with Prostate Cancer

• Effects of Psychosocial Treatment on Cancer Survivorship

• Exercise and Nutrition to Enhance Recovery and Good Health for You (ENERGY)

• Family-based Interventions (The FOCUS Program) for Men with Prostate Cancer and their Spouses/Partners

• Family-Centered Advance Care Planning for Teens with Cancer (FACE-TC)

• Healthy-Steps

• Managing Uncertainty Day-to-Day

• Meaning-Centered Group Psychotherapy for Patients with Advanced Cancer

• Palliative Care Intervention for Caregivers of Lung Cancer Patients

• Palliative Care for Lung Cancer Patients

• Project ENABLE II

• Sleep Healthy Using the Internet (SHUTi)

• Surviving Cancer Competently Intervention Program (SCCIP)

• The Touch, Caring and Cancer Program

• OTHER: [INSERT TEXT]

Tobacco Control [ANSWERS IN DROPDOWN]

Interventions to Reduce Tobacco Use and Secondhand Smoke Exposure

• Comprehensive Tobacco Control Programs

• Internet-based Cessation Interventions

• Interventions to Increase the Unit Price for Tobacco Products

• Mass-Reach Health Communication Interventions

• Mobile Phone Text Messaging Cessation Interventions

• Quitline Interventions

• Reducing Out-of-Pocket Costs for Evidence-Based Cessation Treatments

• Smoke-Free Policies

Incentives and Competitions to Increase Smoking Cessation Among Workers

• When Combined with Additional Interventions

Restricting Minors’ Access to Tobacco Products

• Community Mobilization with Additional Interventions

• OTHER: [INSERT TEXT]

[For each EBI selected in Q18, the following questions will be asked:]

17a. At what scale did you implement this EBI?

• Small-scale: Within a health system

• Small-scale: Within a municipality (or equivalent)

• Medium-scale: Across several counties (or equivalent)

• Large-scale: Multi-recipient or recipient jurisdiction-wide

17b. Did you achieve the outcome(s) of this EBI?

• Yes

  • In 1-2 sentences, please describe what outcomes you were able to achieve and how you were able to achieve this outcome(s):

• [INSERT TEXT]

• No

  • In 1-2 sentences, please describe what outcomes you were not able to achieve and why these outcomes were not achieved:

• [INSERT TEXT]
  
  
  

18. Have you implemented any other EBIs that are not aligned with your specific CCC plan priorities?

    • Yes

18a. What EBI did you implement?

• [INSERT TEXT]

18b. At what scale did you implement this EBI?

• Small-scale: Within a health system

• Small-scale: Within a municipality (or equivalent)

• Medium-scale: Across several counties (or equivalent)

• Large-scale: Multi-recipient or recipient jurisdiction-wide

18c. Did you achieve the outcome(s) of this EBI?

• Yes

  • In 1-2 sentences, please describe what outcomes you were able to achieve and how you were able to achieve this outcome(s):

• [INSERT TEXT]

• No

  • In 1-2 sentences, please describe what outcomes you were not able to achieve and why these outcomes were not achieved):

• [INSERT TEXT]

• No
  
  
  

Section 4: CCC Partnerships contributions to CCC Plan Priorities Implementation

The purpose of the questions in this section is to understand what role partners have in implementing CCC plan priorities and the way partners have contributed to the implementation of your program, and any facilitators/barriers you have encountered in working with partners.

[LINK to EBIs chosen in Q17]

19. When thinking about this specific EBI, please fill out the following table with information about your partners contributions towards resources regarding the implementation of this EBI?
    
    

	# of partners who contribute	List names of partners	Are these resources provided in-kind? Y/N	Leveraged resources* (in dollars) *if in-kind, please provide estimate in dollars
Staff
Funds
Meeting/Intervention space
Travel
Technology
Other: [INSERT TEXT]

Section 5: Program Accomplishments

The purpose of the questions in this section is to learn about program implementation accomplishments.

20. Please indicate the most notable policy change your program has made via program activities to support the following [SELECT ONE]:

• Increased policies that support primary prevention and healthy lifestyle behaviors

• Increased policies that support high-quality cancer screening

• Increased policies that support the needs of cancer survivors

• Health equity

• None of the above

22a. If indicated above:

• What accomplishment are you most proud of related to increasing policies that support primary prevention and healthy lifestyle behaviors? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to increasing policies that support high-quality cancer screening? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to increasing policies that support the needs of cancer survivors? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to increasing policies that support health equity? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

21. Please indicate the most notable health system changes your program has made via program activities to support the following [SELECT ONE]:

• Improved community linkages

• Increased chronic disease self-management support among cancer survivors

• Improved systems to support quality screening

• Increased health extender services

• OTHER: [INSERT TEXT]

23a. If indicated above:

• What accomplishment are you most proud of related to Improving community linkages? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to Increasing chronic disease self-management support among cancer survivors? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to improving systems to support quality screening? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to increasing health extender services? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

22. Please indicate the most notable community/environmental change your program has made via program activities to support the following [SELECT ONE]:

• New or enhanced childcare programs and policies to support cancer prevention activities

• New or enhanced school programs and policies to support cancer prevention activities

• New or enhanced worksite programs and policies to support cancer prevention activities

• New or enhanced adult programs and policies to support cancer prevention activities

• Increased evidence-based lifestyle and wellness survivorship programs

• OTHER: [INSERT TEXT]

24a. If indicated above:

• What accomplishment are you most proud of related to developing new or enhancing childcare programs and policies to support cancer prevention activities? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to developing new or enhancing school programs and policies to support cancer prevention activities? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to developing new or enhancing worksite programs and policies to support cancer prevention activities? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to developing new or enhancing adult programs and policies to support cancer prevention activities? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to increasing evidence-based lifestyle and wellness survivorship programs? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

23. Please indicate the most notable intervention your program has implemented focused on increasing health equity and decreasing disparities related to cancer risk reduction. Please specify the population for which you expect to see decreased disparities. [SELECT ONE].

• Reduced tobacco use or exposure

• Reduced alcohol use

• Reduced UV exposure

• Increased HPV vaccination rates

• Improved physical activity

• Improved nutrition

• Increased early detection of cancer

• Improved cancer care for survivors

• OTHER: [INSERT TEXT]

25a. Please describe the specific population for which you expect to see decreased disparities.

• Specific population: [INSERT TEXT]

25b. If indicated above:

• What accomplishment are you most proud of related to reducing disparities in tobacco use or exposure? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to reducing disparities in alcohol use? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to reducing disparities in UV exposure? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to reducing disparities in HPV vaccination rates? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to reducing disparities in physical activity rates? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to reducing disparities in nutrition quality? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to reducing disparities in early detection of cancer? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to reducing disparities in cancer care for survivors? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

24. Please describe any additional important accomplishments that make you proud and are important for us to know about.

    • [INSERT TEXT]

If “Program Partner” is selected in Q2, then survey skips down to the following partner questions.

Partner Questions

25. What EBI they are currently involved in?

    • [INSERT TEXT]
      
      

26. What role do you play in the implementation of this EBI?

    • Funder

    • Subject Matter Expert

    • Planner

    • Implementor

    • Promoter

    • Evaluator

    • Other: [INSERT TEXT]

27. The following table asks about your organization’s contributions to resources regarding the implementation of the CCC plan.
    
    

	Does your organization contribute the following resources? Y/N	If yes, are these resources contributed in-kind? Y/N	Contributions (in dollars*) *if in-kind, please provide estimate in dollars
Staff
Funds
Meeting/intervention space
Travel
Technology
--
OTHER: [INSERT TEXT]

28. Please indicate the most notable policy change your program has made via program activities to support the following [SELECT ONE]:

• Increased policies that support primary prevention and healthy lifestyle behaviors

• Increased policies that support high-quality cancer screening

• Increased policies that support the needs of cancer survivors

• Health equity

• None of the above

28a. If indicated above:

• What accomplishment are you most proud of related to increasing policies that support primary prevention and healthy lifestyle behaviors? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to increasing policies that support high-quality cancer screening? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to increasing policies that support the needs of cancer survivors? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to increasing policies that support health equity? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

29. Please indicate the most notable health system changes your program has made via program activities to support the following [SELECT ONE]:

• Improved community linkages

• Increased chronic disease self-management support among cancer survivors

• Improved systems to support quality screening

• Increased health extender services

• OTHER: [INSERT TEXT]

29a. If indicated above:

• What accomplishment are you most proud of related to Improving community linkages? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to Increasing chronic disease self-management support among cancer survivors? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to improving systems to support quality screening? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to increasing health extender services? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

30. Please indicate the most notable community and/or environmental change your program has made via program activities to support the following [SELECT ONE]:

• New or enhanced childcare programs and policies to support cancer prevention activities

• New or enhanced school programs and policies to support cancer prevention activities

• New or enhanced worksite programs and policies to support cancer prevention activities

• New or enhanced adult programs and policies to support cancer prevention activities

• Increased evidence-based lifestyle and wellness survivorship programs

• OTHER: [INSERT TEXT]

30a. If indicated above:

• What accomplishment are you most proud of related to developing new or enhancing childcare programs and policies to support cancer prevention activities? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to developing new or enhancing school programs and policies to support cancer prevention activities? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to developing new or enhancing worksite programs and policies to support cancer prevention activities? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to developing new or enhancing adult programs and policies to support cancer prevention activities? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to increasing evidence-based lifestyle and wellness survivorship programs? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

31. Please indicate the most notable intervention your program has implemented focused on increasing health equity and decreasing disparities related to cancer risk reduction. Please specify the population for which you expect to see decreased disparities. [SELECT ONE].

• Reduced tobacco use or exposure

• Reduced alcohol use

• Reduced UV exposure

• Increased HPV vaccination rates

• Improved physical activity

• Improved nutrition

• Increased early detection of cancer

• Improved cancer care for survivors

• OTHER: [INSERT TEXT]

31a. Please describe the specific population for which you expect to see decreased disparities.

• Specific population: [INSERT TEXT]

23b. If indicated above:

• What accomplishment are you most proud of related to reducing disparities in tobacco use or exposure? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to reducing disparities in alcohol use? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to reducing disparities in UV exposure? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to reducing disparities in HPV vaccination rates? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to reducing disparities in physical activity? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to reducing disparities in nutrition quality? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to reducing disparities in early detection of cancer? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]

• What accomplishment are you most proud of related to reducing disparities in cancer care for survivors? Please describe, and, where possible, include numerical data to illustrate these accomplishments. [OPEN ENDED]
  
  

32. Please describe any additional important accomplishments that make you proud and are important for us to know about.

    • [INSERT TEXT]

33. Do you have any other EBIs you are involved in?

    • Yes [If chosen, REPEAT Q25-Q32]

    • No [If chosen, END survey]

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 burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0841).