NCCCP Survey_REDCap - screenshots

Form Approved:
OMB #: 0920-0841
Expiration Date:

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National Comprehensive Cancer Control Program Evaluation 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).

Thank you for participating in this assessment!
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 cyq6@cdcgov 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.

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

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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
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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
Please specify other:

What is your primary role?

Type the name of the organization you are
representing:

__________________________________
Program Director
Program Coordinator/Program Manager
Evaluator
Policy Analyst
Program Partner
Other ______

__________________________________

Please select what sector best represents your
organization:

Government Organization
Non-profit Organization
Academia/Education Organization
Academia/Education Organization - HBCU
Academia/Education Organization - 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: ______

How long have you been in your current role?

Less than 3 years
3 - 5 years
6 - 10 years
Over 10 years

How long have you been working in chronic disease?

Less than 3 years
3 - 5 years
6 - 10 years
Over 10 years

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Are you a member of a CCC coalition?

Yes
No

What best describes your position in the coalition?

Leadership member
Workgroup/Subcommittee member
Member organization representative
Other ______

Please list the workgroups/subcommittees you are a
member of:
Please type the name of your Partnership/Coalition:

__________________________________

__________________________________

Is this Partnership/Coalition part of a 501(c)(3)
organization?

Yes
No
Unsure/Do not know

Is this Partnership/Coalition legislatively mandated?

Yes
No
Unsure/Do not know

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: ______

Does your Partnership/Coalition have workgroups or
subcommittees?

Yes
No

If your Partnership/Coalition does have workgroups or
subcommittees, please select all that apply:

Prevention
Screening
Survivorship
Evaluation
Communication
Policy
Health Equity
Other: ______

Please select how large your Partnership/Coalition is:

Less than 50 individuals
50 - 100 individuals
More than 100 individuals

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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: ______

Is there at least one member organization in your
Partnership/Coalition that officially represents this
group - American Indian or Alaska Native?

Yes
No

Is there at least one member organization in your
Partnership/Coalition that officially represents this
group - Asian?

Yes
No

Is there at least one member organization in your
Partnership/Coalition that officially represents this
group - Black or African American?

Yes
No

Is there at least one member organization in your
Partnership/Coalition that officially represents this
group - Hispanic or Latino?

Yes
No

Is there at least one member organization in your
Partnership/Coalition that officially represents this
group - Native Hawaiian or Other Pacific Islander?

Yes
No

Is there at least one member organization in your
Partnership/Coalition that officially represents this
group - White?

Yes
No

Is there at least one member organization in your
Partnership/Coalition that officially represents this
group - Rural?

Yes
No

Is there at least one member organization in your
Partnership/Coalition that officially represents this
group - Urban?

Yes
No

Is there at least one member organization in your
Partnership/Coalition that officially represents this
group - Frontier?

Yes
No

Is there at least one member organization in your
Partnership/Coalition that officially represents this
group - Faith Based?

Yes
No

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Is there at least one member organization in your
Partnership/Coalition that officially represents this
group - People with disabilities?

Yes
No

Is there at least one member organization in your
Partnership/Coalition that officially represents this
group - LGBTQ+?

Yes
No

Is there at least one member organization in your
Partnership/Coalition that officially represents this
group - Other?

Yes
No

Section 2: CCC Plan

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: ______

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:
Promote the Primary Prevention of Cancer Support
Cancer Early Detection Efforts Address the Needs of
Cancer Survivors 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
Select the topic below that associated with your CCC
plan priorities:
[SELECT ALL THAT APPLY]
How did your program identify ALCOHOL 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:

How did your program identify BREAST CANCER 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:

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How did your program identify CERVICAL CANCER 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:

How did your program identify COLORECTAL CANCER 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:

How did your program identify HEALTH EQUITY 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:

How did your program identify HEPATITIS AND LIVER
CANCER PREVENTION 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:

How did your program identify HEREDITARY (GENETIC)
CANCER SYNDROMES 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:

How did your program identify HUMAN PAPILLOMAVIRUS
(HPV) VACCINATION 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:

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How did your program identify LUNG CANCER 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:

How did your program identify NUTRITION, OBESITY, AND
PHYSICAL ACTIVITY 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:

How did your program identify RADON 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:

How did your program identify SUN SAFETY AND
OVEREXPOSURE TO UV RAYS/SKIN CANCER 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:

How did your program identify SURVIVORSHIP 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:

How did your program identify TOBACCO CONTROL 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:

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How did your program identify OTHER for your CCC plan?

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

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:

__________________________________________

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

__________________________________________

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

__________________________________________

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

__________________________________________

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

__________________________________________

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

__________________________________________

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

__________________________________________

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

__________________________________________

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

__________________________________________

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

__________________________________________

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

__________________________________________

How did your program address this CCC plan priority SUN SAFETY AND OVEREXPOSURE TO UV RAYS/SKIN CANCER?
(e.g., convene coalition workgroup, partner with a
coalition member, identify evidenced based
intervention to implement in annual workplan, etc.)

__________________________________________

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

__________________________________________

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

__________________________________________

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

__________________________________________

How long is the implementation for this priority ALCOHOL?

Less than 1 year
1 - 2 years
3 - 4 years
Up to 5 years

How long is the implementation for this priority BREAST CANCER?

Less than 1 year
1 - 2 years
3 - 4 years
Up to 5 years

How long is the implementation for this priority CERVICAL CANCER?

Less than 1 year
1 - 2 years
3 - 4 years
Up to 5 years

How long is the implementation for this priority COLORECTAL CANCER?

Less than 1 year
1 - 2 years
3 - 4 years
Up to 5 years

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How long is the implementation for this priority HEALTH EQUITY?

Less than 1 year
1 - 2 years
3 - 4 years
Up to 5 years

How long is the implementation for this priority HEPATITIS AND LIVER CANCER PREVENTION?

Less than 1 year
1 - 2 years
3 - 4 years
Up to 5 years

How long is the implementation for this priority HEREDITARY (GENETIC) CANCER SYNDROMES?

Less than 1 year
1 - 2 years
3 - 4 years
Up to 5 years

How long is the implementation for this priority HUMAN PAPILLOMAVIRUS (HPV) VACCINATION?

Less than 1 year
1 - 2 years
3 - 4 years
Up to 5 years

How long is the implementation for this priority LUNG CANCER?

Less than 1 year
1 - 2 years
3 - 4 years
Up to 5 years

How long is the implementation for this priority NUTRITION, OBESITY, AND PHYSICAL ACTIVITY?

Less than 1 year
1 - 2 years
3 - 4 years
Up to 5 years

How long is the implementation for this priority RADON?

Less than 1 year
1 - 2 years
3 - 4 years
Up to 5 years

How long is the implementation for this priority - SUN
SAFETY AND OVEREXPOSURE TO UV RAYS/SKIN CANCER?

Less than 1 year
1 - 2 years
3 - 4 years
Up to 5 years

How long is the implementation for this priority SURVIVORSHIP?

Less than 1 year
1 - 2 years
3 - 4 years
Up to 5 years

How long is the implementation for this priority TOBACCO CONTROL?

Less than 1 year
1 - 2 years
3 - 4 years
Up to 5 years

How long is the implementation for this priority OTHER?

Less than 1 year
1 - 2 years
3 - 4 years
Up to 5 years

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When do you know when a priority is fully addressed ALCOHOL?

Established benchmark is achieved
Policy changes
Reduction in cancer rates
Reallocation of resources to other areas
Other: ______

When do you know when a priority is fully addressed BREAST CANCER?

Established benchmark is achieved
Policy changes
Reduction in cancer rates
Reallocation of resources to other areas
Other: ______

When do you know when a priority is fully addressed CERVICAL CANCER?

Established benchmark is achieved
Policy changes
Reduction in cancer rates
Reallocation of resources to other areas
Other: ______

When do you know when a priority is fully addressed COLORECTAL CANCER?

Established benchmark is achieved
Policy changes
Reduction in cancer rates
Reallocation of resources to other areas
Other: ______

When do you know when a priority is fully addressed HEALTH EQUITY?

Established benchmark is achieved
Policy changes
Reduction in cancer rates
Reallocation of resources to other areas
Other: ______

When do you know when a priority is fully addressed HEPATITIS AND LIVER CANCER PREVENTION?

Established benchmark is achieved
Policy changes
Reduction in cancer rates
Reallocation of resources to other areas
Other: ______

When do you know when a priority is fully addressed HEREDITARY (GENETIC) CANCER SYNDROMES?

Established benchmark is achieved
Policy changes
Reduction in cancer rates
Reallocation of resources to other areas
Other: ______

When do you know when a priority is fully addressed HUMANPAPILLOMAVIRUS (HPV) VACCINATION?

Established benchmark is achieved
Policy changes
Reduction in cancer rates
Reallocation of resources to other areas
Other: ______

When do you know when a priority is fully addressed LUNG CANCER?

Established benchmark is achieved
Policy changes
Reduction in cancer rates
Reallocation of resources to other areas
Other: ______

When do you know when a priority is fully addressed NUTRITION, OBESITY, AND PHYSICAL ACTIVITY?

Established benchmark is achieved
Policy changes
Reduction in cancer rates
Reallocation of resources to other areas
Other: ______

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When do you know when a priority is fully addressed RADON?

Established benchmark is achieved
Policy changes
Reduction in cancer rates
Reallocation of resources to other areas
Other: ______

When do you know when a priority is fully addressed SUNSAFETY AND OVEREXPOSURE TO UV RAYS/SKIN CANCER?

Established benchmark is achieved
Policy changes
Reduction in cancer rates
Reallocation of resources to other areas
Other: ______

When do you know when a priority is fully addressed SURVIVORSHIP?

Established benchmark is achieved
Policy changes
Reduction in cancer rates
Reallocation of resources to other areas
Other: ______

When do you know when a priority is fully addressed TOBACCO CONTROL?

Established benchmark is achieved
Policy changes
Reduction in cancer rates
Reallocation of resources to other areas
Other: ______

When do you know when a priority is fully addressed OTHER?

Established benchmark is achieved
Policy changes
Reduction in cancer rates
Reallocation of resources to other areas
Other: ______

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.
Definitions:
Knowledge - the body of factual information that can be applied.
Ability - the capacity to express a skill.
Skills - the capabilities require to perform tasks accurately.
Novice - Individual is learning to recognize specific objective facts along with fundamental
concepts and specific rules of action.
Advance Novice - Individual is adding to their knowledge of facts, they are recognizing
previously undefined facts, obtaining more information relative to the teaching-learning
process, increasing their knowledge of relevant vocabulary, concepts, and principles.
Competent - Individual is beginning to recognize more context-free principles and concepts as
well as situational elements.
Proficient - Individual can identify the important elements of the task very quickly, very easily.
They have a fluid style that allows them to implement decisions based on intuitive
understandings--understandings
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Expert - Individual is operating in an experienced-based similar to that achieved at the
proficient stage, but in a more holistic manner.
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.

In which priority area have you had the most success
in implementing EBIs?

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.
In which priority area have you had the biggest
challenge in implementing EBIs?

Addressing primary prevention
Supporting early detection
Addressing needs of cancer survivors
Reducing cancer disparities and increasing health
equity

__________________________________________

Addressing primary prevention
Supporting early detection
Addressing needs of cancer survivors
Reducing cancer disparities and increasing health
equity

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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).

__________________________________________

Thinking of the last 2 years, can you select the EBIs that you have implemented during that time that are aligned
with your specific CCC plan priorities? 
    Topic EBI At what scale did you implement this EBI? Did you achieve the outcome(s) of this EBI? (Yes/No) If
yes, in 1-2 sentences, please describe what outcomes you were able to achieve and how you were able to achieve
this outcome(s):
If no, in 1-2 sentences, please describe what outcomes you were not able to achieve and why these outcomes were
not achieved:
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:
______
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______

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Have you implemented any other EBIs that are not
aligned with your specific CCC plan priorities?
What EBI did you implement?

Yes
No

__________________________________

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

Did you achieve the outcomes(s) of this EBI?

Yes
No

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

__________________________________________

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

__________________________________________

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.

Please fill out the following table with information about your partners contributions towards resources regarding
the implementation of EBI(s)?
  # 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
______ ______ ______ ______

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Section 5: Program Accomplishments
The purpose of the questions in this section is to
learn about program implementation accomplishments.

Please indicate the most notable policy change your
program has made via program activities to support the
following

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
Increased policies that support health equity
Other ______

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.

__________________________________________

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.

__________________________________________

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.

__________________________________________

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.
Please indicate the most notable health system changes
your program has made via program activities to
support the following

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

07/06/2023 12:07pm

__________________________________________

Improved community linkages
Increased chronic disease self-management support
among cancer survivors
Improved systems to support quality screening
Increased health extender services (i.e.,
community health workers, patient navigators, etc.)
Other ______

__________________________________________

__________________________________________

__________________________________________

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

__________________________________________

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: ______

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.

__________________________________________

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.

__________________________________________

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.

__________________________________________

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.

__________________________________________

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.

__________________________________________

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.

Please describe the specific population for which you
expect to see decreased disparities.
• Specific population:

07/06/2023 12:07pm

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: ______

__________________________________

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

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________________

__________________________________

What EBI are you currently involved in?
What role do you play in the implementation of this
EBI?

07/06/2023 12:07pm

Funder
Subject Matter Expert
Planner
Implementor
Promoter
Evaluator
Other: ______

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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*: ______ ______ ______
*Other

Please indicate the most notable policy change your
program has made via program activities to support the
following

07/06/2023 12:07pm

__________________________________
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
Increased policies that support health equity
Other ______

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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.

__________________________________________

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.

__________________________________________

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.

__________________________________________

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.
Please indicate the most notable health system changes
your program has made via program activities to
support the following:

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

07/06/2023 12:07pm

__________________________________________

Improved community linkages
Increased chronic disease self-management support
among cancer survivors
Improved systems to support quality screening
Increased health extender services (i.e.,
community health workers, patient navigators, etc.)
Other: ______

__________________________________________

__________________________________________

__________________________________________

__________________________________________

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Please indicate the most notable community and/or
environmental change your program has made via program
activities to support the following:

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 ______

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.

__________________________________________

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.

__________________________________________

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.

__________________________________________

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.

__________________________________________

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.

__________________________________________

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.

Please describe the specific population for which you
expect to see decreased disparities.
• Specific population:
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.

07/06/2023 12:07pm

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: ______

__________________________________

__________________________________

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Page 23

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.
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.
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.
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.
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.
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.
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.
Please describe any additional important
accomplishments that make you proud and are important
for us to know about.
Do you have any other EBIs you are involved in?

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________________
Yes
No

Thank you for your time!

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