Form Approved
OMB No. 0920-XXXX
Exp. Date xx/xx/20xx
In-Depth Assessment – Evaluability Assessment Nomination Form – The National Cardiovascular Health Program & The Innovative Cardiovascular Health Program
Note:
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Evaluability Assessment
Nomination Form
Thank you for your interest in participating in the [Insert Cooperative Agreement] Evaluability 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)]. c
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
Please select your [insert Cooperative Agreement] recipient name.
[Drop-down list of Recipients]
(Programming: New Page)
Recipient Information
Please answer the following set of questions regarding your organization.
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) |
In what city, county, and state is your organization based?
City
County
State
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 [insert Cooperative Agreement] 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.
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
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)
We will review your [insert Cooperative Agreement] 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)
What implementation goals do you intend to achieve by the end of the cooperative agreement?
(open text)
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 [insert Cooperative agreement] (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 [insert Cooperative agreement] (100% mature)
Briefly describe your history of implementing [insert selected strategy from Q5] under prior cooperative agreements or initiatives.
(open text)
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)
Do you implement cardiac rehabilitation as part of this program?
Yes
No
Do you implement activities related to hypertension among women?
Yes
No
Do you implement activities related to hypertension among pregnant or postpartum people?
Yes
No
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
Women
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
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
Are you implementing a similar strategy under another DHDSP cooperative agreement (i.e., The National CVH Program, The Innovative CVH Program, WISEWOMAN).
Yes
No
(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
Please select the sub-strategies your organization is evaluating as part of your recipient-led evaluation. (Select all that apply).
[Drop-down list of Cooperative Agreement-specific sub-strategies for the nominated strategy]
What is the Learning Collaborative’s role in implementation, data collection, and evaluation for the nominated strategy?
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 [insert Cooperative Agreement] performance measure reporting.
Provide additional data to the Comprehensive Evaluation on partner implementation and outcomes.
(Programming: New Page)
Partner and Learning Collaborative 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 and learning collaborative (LC) collaborators 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.
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)
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) |
Are Learning Collaboratives (LC) supporting the strategy selected for nomination?
Yes
No
(Programming: If respondent selects “Yes” in Q21) How does the LC support implementation of the nominated strategy? (Open response item)
(Programming: If respondent selects “Yes” in Q221) Please provide the following information about the LC collaborators and partners that support the strategy selected for nomination.
Who is the LC Lead? |
(open text) |
LC Lead Email Address |
(open text, with email validation) |
LC Lead Phone Number |
open text, with phone number validation) |
Who is the staff person focused on health equity? |
(open text) |
Who are the LC collaborators and partners? |
(open text) |
What percentage of the LC collaborators and partners represent the populations of focus? |
(open text, with number validation) |
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)
(Programming: If respondent selects “Yes” in Q24) 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
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
(Programming: This question will be asked if respondent selects “Somewhat unlikely” or “Very unlikely” in Q26). Please explain why your organization and recommended partners are unlikely to participate in the Exploratory Assessment.
(open text)
Does your organization have the ability to report hypertension control by sex?
Yes
No
Is your organization willing to report hypertension control by sex?
Yes
No
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
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].
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Dee Dee Wei |
| File Modified | 0000-00-00 |
| File Created | 2024-11-09 |