0920-24FI In-Depth Assessment – Evaluability Assessment Nomination

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

In-Depth Assessment – Evaluability Assessment Nomination Form – WISEWOMAN

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Evaluability Assessment

Nomination Form

Thank you for your interest in participating in the WISEWOMAN Assessment, a component of CDC’s Division for Heart Disease and Stroke Prevention (DHDSP) Comprehensive Evaluation. For additional information about the Evaluability Assessment and the request for nominations, please review the [insert accompanying communication materials (e.g., flyer, frequently asked questions)].

Please answer the following questions to nominate a strategy that your organization is implementing. The information that you provide will help us understand your program and inform decisions about which nominees will be invited to participate in the Evaluability Assessment.

The nomination form will take approximately 30 minutes to complete. Nominations must be submitted no later than [insert date from communication].

Your participation is voluntary. You may skip any questions you do not want to answer for any reason. There are no known risks or direct benefits to you for completing this nomination form. The information you provide will help inform the final participation list for the Evaluability Assessment.

Evaluability Assessment Participation

1. Please select your WISEWOMAN recipient name.

   • [Drop-down list of Recipients]

(Programming: New Page)

Recipient Information

Please answer the following set of questions regarding your organization.

2. Please provide information for the best person to communicate with regarding the Evaluability Assessments.

Point of Contact Name	(open text)
Point of Contact Job Title/Position	(open text)
Organization Name	(open text)
Point of Contact Email Address	(open text, with email validation)
Point of Contact Phone Number	(open text, with phone number validation)

3. In what city, county, and state is your organization based?

• City

• County

• State

4. Which of the following DHDSP cooperative agreements did your organization receive in the past? Select all that apply.

• [Drop-down list of predecessor cooperative agreements]

(Programming: New Page)

Strategy Implementation

The Evaluability Assessment will focus on one of the WISEWOMAN strategies you are implementing. The next set of questions will ask you more about the strategy you would like to nominate for the Evaluability Assessment and your organization’s implementation of that strategy.

5. Which strategy are you nominating for the Evaluability Assessment? (Please select one)

• Strategy 1: Track and Monitor Clinical Measures

• Strategy 2: Implement Team Based Care

• Strategy 3: Link Community and Clinical Services

6. Please describe why you selected the strategy. (Considerations may include the strategy you have had the most progress with, the strategy you are most excited about, the strategy with an innovative implementation approach, etc.)

• (open text)

(Programming: Q7-18 will include branching logic based on the response to Q5 to ask questions about the nominated strategy)

7. We will review your WISEWOMAN workplan for the strategy you selected for nomination. What else should we know about your implementation or approach for [insert selected strategy from Q5]?

   • (open text)

8. What implementation goals do you intend to achieve by the end of the cooperative agreement?

   • (open text)

9. How would you rate the current level of maturity for the sub-strategies? (Programming note: Question presented in grid format for each sub-strategy)

• Start up: Initiation of sub-strategy for the first time under the WISEWOMAN (25% mature)

• Growth: Sub-strategy is gaining traction, increasing number of sites, participation from population of focus (50% mature)

• Expansion: Sub-strategy has not only gained traction but has now expanded to desired size and reach (75% mature)

• Maintenance: Activities are established and expected continuation of sub-strategy post WISEWOMAN (100% mature)

10. Briefly describe your history of implementing [insert selected strategy from Q5] under prior cooperative agreements or initiatives.

    • (open text)

11. In what settings do you implement your programs and services related to [insert selected strategy from Q5]? (e.g., primary care clinics, pharmacies, community-based organizations, Federally Qualified Health Centers, health systems, etc.)?

• (open text)

12. Do you implement cardiac rehabilitation as part of this program?

    • Yes

    • No

13. Do you implement activities related to hypertension among pregnant or postpartum people?

• Yes

• No

14. Please identify the population(s) of focus for your work in [insert selected strategy from Q5]. Select all that apply.

    • Black or African American

    • Asian

    • Hispanic or Latino 

    • American Indian or Alaska Native

    • Native Hawaiian or Other Pacific Islander

    • Pregnant or postpartum people

    • People with disabilities 

    • People living in rural communities 

    • People who are migrant workers 

    • People living near, at, or below the poverty level

    • People who are uninsured or under-insured 

    • People within census tracts with a hypertension crude prevalence of 53% or higher

    • Other, please specify 

    • Not applicable – this program does not implement any targeted activities 

15. How would you describe the geography of program sites you are partnering with to implement [insert selected strategy from Q5]? Select all that apply.

• Urban

• Rural

• Suburban

16. Are you implementing a similar strategy under another DHDSP cooperative agreement (i.e., The National CVH Program, The Innovative CVH Program).

    • Yes

    • No

17. (Programming: If respondent selects “Yes” in Q14) Are you interested in conducting an evaluability assessment of the strategy across all the cooperative agreements where the nominated strategy is being implemented?

(Programming: New Page)

Strategy Evaluation

18. Beyond evaluating <sub-strategy 1A, 2B, 3C> for the recipient-led evaluation, are you evaluating any other sub-strategies? Select all that apply.

    • Yes

    • No

19. (Programming: If respondent selects “Yes in Q16) Please describe the additional evaluation activities for the sub-strategies you are evaluating. (Open response item)

    • (open text)

20. How likely is your organization to complete the following evaluation activities for the nominated strategy by the end of Program Year 2? (Programming note: Question presented in grid format; Response options: Very likely, Somewhat likely, Somewhat unlikely, Very unlikely)

    • Implement Year 2 of the recipient-led evaluation plan (i.e., process evaluation).

    • Report early implementation outcomes for the strategy.

    • Report process evaluation findings for the strategy.

    • Report early health outcomes for the strategy.

    • Report performance measures for each sub-strategy.

    • Collect quantitative data from partners (e.g., enrollment, participation, referrals, health outcomes) that are not part of the WISEWOMAN performance measure and/or MDE reporting.

    • Provide additional data to the Comprehensive Evaluation on partner implementation and outcomes.

(Programming: New Page)

Partner Information

Some recipient partners will be contacted to participate in the Evaluability Assessment to understand their role in supporting strategy implementation, partner-specific facilitators/barriers and their progress towards outcomes. Please identify partners that support the strategy selected for nomination that you recommend for participation in the Evaluability Assessment.

The following section will ask you a set of questions for each partner that supports implementation and that you recommend including in the Evaluability Assessment. The Comprehensive Evaluation Team will use your responses to understand strategy implementation and plan data collection activities. The Comprehensive Evaluation Team will collaborate with recipients to confirm the final partner list and develop a communication plan prior to contacting any partners.

21. How many partners are you recommending that support the nominated strategy? Please enter a number between 1 and 10. (Programming Note: Open response item with number validation. The response will branch to a page that has space to provide partner information for the number of partners identified)

22. Please complete the following information about the partner(s) that supports the nominated strategy and identify the best point of contact for each partner. Please note that we will not conduct any outreach until the participant selection for the Evaluability Assessment is finalized, and we will not contact partner organizations without your awareness. (Programming Note: the table will be repeated for the number of partners identified in Q19)

Organization Name	(open text)
Organization Location (City)	(open text)
Organization Location (State)	(open text)
Organization Type (e.g., non-profit, academic institution, health system, etc.)	(open text)
Point of Contact Name	(open text)
Point of Contact Job Title/Position	(open text)
Point of Contact Email Address	(open text, with email validation)
Point of Contact Phone Number	(open text, with phone number validation)
Partner’s role in strategy implementation	(open text)
Partner population(s) of focus	(open text)
Is this a new or existing partner?	(drop-down with response options: new, existing)
How many years do you anticipate collaborating with this partner for the nominated strategy?	(drop-down with response options: 1, 2, 3, 4, 5)

23. Are there any other partners that should be included in the Evaluability Assessment that you have not already identified?

    • Yes

    • No (Programming: Skip to the next section)

24. (Programming: If respondent selects “Yes” in Q21) Please provide the additional partner’s name, role and contact information in the space provided.

    • (open text)

(Programming: New Page)

Participation in Future Comprehensive Evaluation Activities

25. If selected to participate in the Evaluability Assessments, how likely are your organization and recommended partners to also participate in the Exploratory Assessments?

• Very likely

• Somewhat likely

• Somewhat unlikely

• Very unlikely

26. (Programming: This question will be asked if respondent selects “Somewhat unlikely” or “Very unlikely” in Q23). Please explain why your organization and recommended partners are unlikely to participate in the Exploratory Assessment.

    • (open text)

27. Would your organization be willing to participate in a pilot of the Cost Study tool, a tool that will be used to assess implementation costs for the cooperative agreement?

• Yes

• No

(Programming: New Page)

Closing

28. Is there anything else you would like the Comprehensive Evaluation Team to know about your program or participation in the Evaluability Assessment? (Open response item)

    • (open text)

Thank you for completing the Evaluability Assessment nomination form. If you have any additional questions, please feel free to contact the Comprehensive Evaluation Team, [email protected]