Example Data Collection Instruments

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[NOISH] Assessing Adoption and Implementation of the National Institute of Occupational Safety and Health’s (NIOSH) Outputs

Example Data Collection Instruments

OMB: 0920-1450

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Appendix A. Example Data Collection Instruments

In this appendix, we provide an example informed consent form and examples of surveys, focus group guides, interview guides, and other methods that might be adapted for use under this information request mechanism.

Example 1: Sample Informed Consent Form for virtual and in-person interviews with employer-based trainers preparing for and delivering training using a NIOSH online heat stress training module

Consent to be in a Research Study Use of NIOSH Heat Stress Training Module
1	Who is conducting the study?				The National Institute for Occupational Safety and Health (NIOSH) is a federal agency that studies worker safety and health. We are part of the Centers for Disease Control and Prevention (CDC). Our website is: https://www.cdc.gov/niosh/index.htm
2	What is the purpose?				The purpose of this research study is to understand how employers delivered and used a NIOSH heat stress training module. The results will help us improve and expand heat stress prevention resources to meet the needs of employers and trainers.
3	What will I do?				You will participate in online or in-person or interviews before and after the training session you provide. We will schedule the interviews at times that are convenient for you. If the interview is online, you will be sent a Microsoft Outlook calendar invitation for the date and time, which will contain a Zoom for Government web link. The initial (before) interview will last 30-40 minutes. We will ask how you prepared to provide the training, whether the module resources were adequate, and what gaps you perceived. The post training session interview (after) will last about 40-45 minutes. We will ask you for feedback about the session, whether the module prepared you, what improvements you suggest, and how the training participants felt about the training. If you provide multiple trainings over the study, we may ask you to complete a second post-training interview. We will ask about additional feedback you might have. If your employer uses multiple trainers, we may conduct interviews among small groups of trainers.
4	When, where, for how long will I be needed?				When: At a date and time that is convenient for you Where: Any private location in your offices (for an in-person interview) or any location where you have phone or internet access. How long: Total of 70 – 85 minutes for two interviews – 100 – 115 for three interview
5	Are there any risks?				This study has minimal risk. The only risks you may experience are potential discomfort with questions and the risk of the loss of confidentiality. You are free to answer as many or as few questions as you would like, and you may stop the interview at any time, for any reason. Signing this form does not mean you have to answer every question we ask and you don’t have to tell us the reason you don’t want to answer a question. We will take every reasonable precaution to keep your information secure. We will take notes of your responses but will not include any identifying information such as your name or the name of the company that you work for. Interviews conducted virtually will use ZoomGov, which has a high level of security authorization. To ensure accurate data collection, we will audio record your responses but will not include identifying information on the recording. After the audio recordings are transcribed, we will destroy the recording. There is a very small potential for a data security breach, but we will de-identify transcribed data so it is unlikely that any data can be directly linked to you. For in-person participants, there is a very small risk that you could get a respiratory infection (e.g., COVID-19, influenza) through an in-person interaction while participating in this study. To minimize your risk of exposure to viruses and maximize your protection against infection, NIOSH researchers follow COVID-19 and other relevant respiratory infectious disease guidance for CDC and NIOSH staff and workplaces.
6	Is my participation voluntary?				Your participation in the study is voluntary. You may choose to answer any or all questions. You may decline to participate or drop out at any time, for any reason, with no penalty or loss of benefits to which you are otherwise entitled.
7	What if I am injured or harmed at a NIOSH research facility or at another location where the NIOSH research project is being conducted?				NIOSH will follow employer protocols. NIOSH will summon emergency medical aid by calling 911 if needed. NIOSH will not provide payment for medical care or compensation. If you believe NIOSH has been negligent in conducting the research study and you believe you have suffered a harm as a result, you have the right to pursue a legal remedy under the Federal Tort Claims Act (28 U.S.C. §§ 2671-2680 and 28 U.S.C. § 1346(b)). To learn more about how to file a Federal Tort claim, call the General Law Division of the HHS Office of the General Counsel at (202) 619-2155 or go to https://‌www.hhs.gov/‌about/‌agencies/‌ogc/‌key-personnel/‌general-law-division/‌index.html.
8		Will I be reimbursed or paid?		You will not be reimbursed or paid for your time.
9		Are there other benefits?	Participants will receive no direct benefits. Knowledge gained from this study can help NIOSH develop more effective heat stress training resources.
10		What alternative procedures might benefit me?	No alternative procedures are available for this study.
11		Will my personal information be kept private?	Your information will be kept private and secure. Recorded notes will be maintained on secure NIOSH servers. All notes will be deidentified. These de-identified recorded notes may be used for future planning for the Miner Health Program but will not be used in any way that can identify the participant. This research project has a Certificate of Confidentiality from the Centers for Disease Control and Prevention (CDC). Unless you say it is okay, researchers cannot release information that may identify you for a legal action, a lawsuit, or as evidence. This protection applies to requests from federal, state, or local civil, criminal, administrative, legislative, or other proceedings. As an example, the Certificate would protect your information from a court subpoena. There are some important things that you need to know. The Certificate DOES NOT protect your information if a federal, state, or local law says it must be reported. For example, some laws require reporting of abuse, communicable diseases, and threats of harm to yourself or others. The Certificate CANNOT BE USED to stop a federal or state government agency from checking records or evaluating programs. The Certificate DOES NOT stop reporting required by the U.S. Food and Drug Administration (FDA). The Certificate also DOES NOT stop your information from being used for other research if allowed by federal regulations. Researchers may release your information when you say it is okay. For example, you may give them permission to release information to insurers, your doctors, or any other person not connected with the research. The Certificate of Confidentiality does not stop you from releasing your own information. It also does not stop you from getting copies of your own information.
12		Will I or anyone else receive study results?	Information will be used by NIOSH to determine what further resources are needed for heat stress training in the mining industry. We will provide you with a brief verbal and written report of your results. We may present or publish a summary of our findings but these will not identify participants in any way.
13		Who can I talk to if I have more questions?	For questions about the research study, contact the principal investigator, _____________________________. For questions about your rights, your privacy, or harm to you, contact the Chair of the NIOSH Institutional Review Board (IRB) in the Human Research Protection Program at 513-533-8591.

Example 2: Demographic questions with measures will be used from updated OMB standards and guidance. Generally, individual and organizational information will be collected via a series of demographic questions which will vary, based on NIOSH products, services, and guidance of interest in the study.

DEMOGRAPHICS

Subject ID #: ________________

Example 3: NIOSH Product Survey (selection and order of questions would vary depending on product/project/service /technology being assessed and the audience/end user group).

The National Institute for Occupational Safety and Health (NIOSH) would like to hear how your organization may have used its products. Whether your organizations directly participated in the research or has received, used, or heard about our products through other sources, NIOSH is interested in learning your opinion about how it can better plan for and subsequently inform key interest holders, such as yourself, about future NIOSH products in your industry.

NIOSH is a non-regulatory federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness. NIOSH is part of the Centers for Disease Control and Prevention (CDC) in the Department of Health and Human Services.

This survey aims to learn how your organization may or may not have used NIOSH products related to [insert outcome or topic]. Example products include databases, new or improved analytic methods, publications, new technologies, trainings, and websites.

Participation is completely voluntary, and any information gathered will not be reported on an individual basis. Only [who will see the data] will receive the survey results. Findings will be summarized across all participants. Individual responses to open-ended comments may be provided, but any identifying information will be removed.

If you have any questions about this survey, please contact: [contact info]

Individual and Organization Information

We would first like to know a little more about you and your organization. This information will help NIOSH learn how their work affects organizations of different sizes and people with different roles.

Which of the following best describes your role in your organization?
1. Occupational safety and health professional
2. Executive
3. Management
4. Front line worker
5. Educator
6. Researcher
7. Legal
8. Regulation enforcement
9. Student
10. Third party consultant

Which of the following best describes your organization?
1. Private business
2. Government agency (federal, state, or local)
3. Non-profit organization
4. Labor association
5. Industry association
6. Institution of higher education
7. Insurer
8. Manufacturer or distributor
9. Other (please specify) ________________________________
What industry is most connected to your organization?
1. Agriculture, Forestry & Fishing
2. Construction
3. Healthcare & Social Assistance
4. Manufacturing
5. Mining
6. Oil and Gas Extraction
7. Public Safety
8. Public Services
9. Transportation, Warehousing, and Utilities
10. Wholesale and Retail Trade
11. Multiple industry sectors

Approximately how many employees does your organization have?
1. 1-49
2. 50-99
3. 100-249
4. 250-499
5. 500-999
6. 1,000 or more
7. I do not know

Awareness and Use of NIOSH Products

The next series of questions ask about your awareness and use of NIOSH products based related to [insert outcome or topic].

8. Are you aware of any of the following NIOSH products (select all that apply)?

Product 1
Product 2
Product 3
I am not aware of any of the listed products.

*Respondents who select “d” will end the survey.

9. How did you hear about the NIOSH products? Check all that apply.

	Product #1	Product #2	Product #3
Direct information from NIOSH researchers/staff
In person visit
Organization participated in the research study that resulted in….
Email; phone, virtual meeting
Conference presentation or meeting
NIOSH exhibit booth at conference
NIOSH hosted webinar
Information from NIOSH sources
NIOSH website
NIOSH eNews, newsletters, social media, or science blogs
NIOSH numbered publication (NIOSH Alert, infographic, or criteria document)
NIOSH article published in an academic journal
NIOSH article published in a trade magazine
Information from other sources
Someone at your organization
Career/job center
Union
Trade association
Professional association
Other government agency (e.g. OSHA)
Insurer
External trainer or consultant
Other (please specify) ______________

NIOSH Product Adoption and Implementation

10. When thinking about the overall usefulness of this product:

It meets safety and health needs of my organization….

	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
Product #1
Product #2
Product #3

It is easy to apply in my organization…

	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
Product #1
Product #2
Product #3

It is important to improving safety and health in my organization…

	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
Product #1
Product #2
Product #3

11. Please describe what made [product #] useful (i.e., met the safety and health needs, made it easy to apply, and made it important) to your organization?

12. Please describe what changes could be made to [product #] or what new product could be developed to make the information more useful (i.e., meet safety and health needs, make it easy to apply, and make it important) to your organization?

13. When does your organization plan to use the NIOSH product(s)?

	Product #1	Product #2	Product #3
*My organization intends* to use this NIOSH product….**
In a few weeks
In a few months
In the next six months
One year
Two-Three Years
Four or more years
Now
Already using
Never or at least have no current plans to use
*My organization has been using* this NIOSH product….**
For a few weeks
For a few months
For 6-11 months
One year
Two-Three years
Four or more years
Never or at least have no current plans to use
My organization has already used this product

*Respondents who select “Never or at least no current plans to use” will skip to question 16.

14. How does your organization intend to use the NIOSH product(s)? (Check all that apply).

	Product #1	Product #2	Product #3
*My organization intends* to use this product to….**
Identify the highest priority occupational safety and health issues
Implement or change occupational safety and health policies
Implement or update occupational safety and health training
Implement or update occupational safety and health practices or methods
Further scientific research
Further disseminate occupational safety and health information
Commercialize a technology
Other (please specify) ___________________________

*Only respondents who select “in a few weeks, in a few months, in 6 months, one year, 2-3 year, or four or more years” on question 13 will answer question 14.

15. How had your organization used the NIOSH product(s)? (Check all that apply).

*My organization has used* or intends to use this product to….**
Identify the highest priority occupational safety and health issues
Implement or change occupational safety and health policies
Implement or update occupational safety and health training
Implement or update occupational safety and health practices or methods
Further scientific research
Further disseminate occupational safety and health information
Commercialize a technology
Other (please specify) ___________________________

*Only respondents who indicate they have used at least one NIOSH product on question 13 will answer question15.

16. Please explain why your organization did not use the NIOSH product(s) and describe the barriers and challenges faced.

*Respondents who select “Never or at least no current plans to use” will skip to question 21.

17. Please explain why your organization intends to or has used the NIOSH product(s).

18. Please describe any challenges your organization experienced implementing the NIOSH products and why?

*Only respondents who indicate they have used at least one NIOSH product on question 13 will answer question 18.

*For respondents who indicate they have used at least one NIOSH product.

19. How many employees are impacted by the use of product #?

a. None

b. 1-49

c. 50-99

d 100-249

e. 250-499

f. 500-999

g. 1,000 or more

h. I do not know

*Repeat for each product used.

20. How likely is your organization to sustain use of product #?

a. Very likely

b. Somewhat likely

c. Somewhat unlikely

d. Very unlikely

e. I don’t know

21. How can NIOSH improve product development in the future?

Example 4: Key Informant and End User(s) Semi-structured Interview/Focus Group Guide

Selection and order of questions would vary depending on product/project/service/technology being assessed and the audience/end user group.

*Introduce/discuss product(s) being discussed in the interview.

Overview/Use

Describe your perception of the implementation of the product/technology.
1. Was it of good quality? Effective?
For you personally, what is the significance of [this product]? (in other words, what is the main benefit)?
For your organization, what is the significance of [this product]?
For your industry, what is the significance of [this product]?
Discuss how [this product] has been used by:

You…
Your organization…
Your industry…

to improve worker safety and health? [As appropriate and seek details regarding where, when, and by whom. Examples may include, but are not limited to:

Research used in setting standards, policy, or guidance
Changes implemented by employers or workers
Research used in setting standards, guidance or policy
Others build on knowledge to pursue additional research or service
Technology commercialized
Others share research findings]

PROBE: Has this improvement in [example discussed] been measured?

How often is this [product/technology] used?
What feature/aspect of the [product/service/technology] is most valuable to you?
1. Design
2. Information
3. Plain language
4. Accessibility
What is still missing from this [product/technology] solution?

Reach/Relevance/Effectiveness

How did [you/your organization] find out about [this product/technology]?

[Seek information about each NIOSH output]

PROBE: What other ways do [you/organization] commonly learn about similar information?

[Seek information about specific websites, newsletters, etc.]

To what extent did the [product/technology] meet the needs of intended users?

Organizational Implementation

Please describe any barriers or challenges experienced during implementation of [product/technology].
Describe facilitators, or things that made implementation easier.
Please tell me about any efforts to maintain this change.
1. PROBE: Describe any barriers or challenges experienced during maintenance.
2. PROBE: Describe facilitators, or things that made maintenance easier.

[Seek examples about each factor]

Impact/Changes

How many employees at your organization (approximately) were affected by this?
1. PROBE: Were contractors or temporary workers also affected? If so, how many?
What impact, if any, has this change had on worker safety and health at your organization?

[Seek examples, which may include, but are not limited to:

Reduction in health/safety outcome, lost productivity, fatigue, stress, etc.
Increased protection offered to workers, improved compliance, etc.
Changes in attitudes and behaviors
Return on investment]

PROBE: Has this impact been measured? If so, how?

What other factors might your organization consider when deciding whether to implement new or make changes to existing safety and health policies and practices?
What can we do better next time to have more impact on safety and health?
To what degree are these impacts sustainable?

Example 5: Interview guide example to assess the familiarity and use of NIOSH’s Health Hazard Evaluation Program

Selection and order of questions would vary depending on product/project/service/technology being assessed and the audience/end user group.

Intro & Rapport-Building Questions

What does your typical workday look like?
1. What got you into doing this kind of work?
How long have you been working with [ORGANIZATION]?
In your organization/worker center, what kind of work do your clients do?
1. What workplace issues does your organization/worker center help them with?
2. What are some specific issues that affect their health and safety? (What do worker center employees think of when they think about health and safety?)
3. What kind of injuries and illness do your clients experience?

Personal Experiences – CONTEXT – Now, we would like to better understand worker experiences related to safety and health in the workplace and the communication and resources that exist to resolve these issues.

What’s an example of a time you helped a worker with a workplace health or safety issue?
1. Probes (ask as needed):
  1. Tell me a little more about the [health/safety issue].
  2. What were some challenges you encountered?
  3. What resources did you consult when trying to solve the problem?
  4. What people did you consult?
  5. How did you resolve the issue?
  6. What was the outcome?
What other kinds of health and safety issues have you helped workers with in the workplace? -
1. What were the outcomes of these health and safety issues for the workers?
Let’s discuss the adequacy of health and safety protections and training for your workers’ places of employment.
1. Is the health and safety training adequate? Why or why not?
2. Please share any examples of adequate/inadequate training. What about preparedness.
How comfortable and motivated are clients in asking your organization/worker center for help with health and safety issues?
1. Why do you think they are comfortable/not comfortable?
2. What makes you think they are motivated/not motivated?
Let’s talk about some ways you have assisted workers with health and safety issues. Specifically:
1. What particular programs have you used?
2. What types of personnel/people have you used?
3. What other resources have taken advantage of to assist workers with health and safety issues?
Describe some of the cultural values that you have noticed within the health and safety in communities you work with.
1. Probe cultural values based on region, workers served, work type, etc. as appropriate to better understand beliefs, social norms, and environmental influences.
How prepared do your clients feel to manage workplace health and safety issues?
1. Do they feel comfortable reporting health and safety concerns to their employers?
  1. What makes you think they are comfortable/not comfortable?

Knowledge – We briefly discussed resources already. Now, I would like to discuss your familiarity and application of NIOSH resources in a little more detail.

What is your understanding of the roles of NIOSH for workers?
Have you ever heard of NIOSH’s Health Hazard Evaluation Program (also called the HHE program)? If yes:
1. What do you know about NIOSH’s Health Hazard Evaluation Program?
2. How did you first hear about the program?
3. Approximately how long have you known about it?
4. Do you know anyone who has used the program?
INTRODUCE HHE PROGRAM: Describe the program – share screen with brochure

[If aware]: Do you know the following information:
1. Health and safety issues that can be addressed?
2. What you need to make a request?
3. Confidentiality for employees?
Can you think of a health or safety situation where this program could be useful to the workers you serve?
1. If not, what situations, if any, do you think it may be helpful in?
If not, why do you think it would not be useful?
Requests can be made online or by phone. Could you see yourself helping a worker make a request online? By phone?
1. Are there other ways to make a request that would be more useful than online or by phone?
What may hinder a worker from making a request to the HHE program?
1. Is there anything NIOSH could do to mitigate these barriers?
How could NIOSH better communicate with worker centers like yours about the HHE program?
1. Are you aware of other programs or services that sound similar to the NIOSH HHE Program? If yes:
  1. Please describe them.
  2. Where did you hear about these programs?
Is there more you would like to see NIOSH doing to help workers in low-wage industries?

Example 6: NIOSH Fire Fighter Fatality Investigation and Prevention Program Survey (selection and order of questions would vary depending on product/project/service/technology being assessed and the audience/end user group)

Every year, 80 to 100 firefighters die in the line of duty. When line of duty deaths occur, the National Institute for Occupational Safety and Health (NIOSH) Fire Fighter Fatality Investigation and Prevention Program (FFFIPP) conducts independent investigations of firefighter fatalities and makes recommendations for avoiding similar incidents. NIOSH is interested in learning more about the safety practices of the United States Fire Service, as well as firefighter familiarity with the NIOSH FFFIPP investigation reports (aka Line of Duty Death (LODD) Investigation Reports). Your responses will help us improve the quality of the reports and how NIOSH distributes the information found in these reports.

In the last few weeks, you should have received a message from one of the national fire service organizations explaining this study and how we will protect your privacy. The survey will take approximately ## minutes. Your responses to the questions will be combined and reported with those from other survey respondents and will be kept confidential. Your participation is voluntary, and you may decline to answer any question or end the survey at any time. Chief Officers and Company Officers completing the survey may need to refer to their department’s response data to respond to a few of the survey items (e.g., National Fire Incident Reporting System (NFIRS), records management system (RMS), CAD, or annual report).

The following questions ask about you and your fire department. They will help us understand your role and your responses as they relate to the size of your fire department.

Where is your fire department located? [Dropdown list of States]

What is your position within the fire department? Please select only one.

☐ Chief Officer (e.g., Fire Chief, Assistant Chief, Deputy Chief, Division Chief, or Battalion Chief)

☐ Company Officer (e.g., Captain, Lieutenant, Sergeant) [SKIP to Company Officer Section]

☐ Firefighter (e.g., Firefighter, Private, Master Firefighter) [SKIP to Firefighter Section]

*************************************************************************************

FIREFIGHTER SECTION

Are you a paid, paid on call, or volunteer firefighter?

☐ Paid

☐ Paid on call

☐ Volunteer

☐ Combination

How many years have you been in the fire service?

☐ Less than one year

☐ 1-2 years 11 months

☐ 3-4 years 11 months

☐ 5-9 years 11 months

☐ 10-14 years 11 months

☐ 15-19 years 11 months

☐ 20-30 Years

☐ More than 30 years

☐ Decline to respond

Has your department or a neighboring jurisdiction experienced a line of duty death? Please select all that apply.

☐ Yes, in my department

☐ Yes, in a neighboring jurisdiction

☐ No [SKIP to Q6]

☐ Don’t know [SKIP to Q6]

☐ Decline to respond [SKIP to Q6]

How long ago did the fatality occur?

☐ Within the past year

☐ 1-2 years 11 months ago

☐ 3-5 years ago

☐ More than 5 years ago

☐ Don’t know

☐ Decline to respond

Did the NIOSH firefighter fatality investigation program investigate the death(s)?

☐ Yes

☐ No

☐ Don’t know

☐ Decline to respond

Fire departments receive health and safety information from many different organizations. The following questions explore where your department receives information and your knowledge of NIOSH’s FFFIPP.

Please indicate which organizations your department has received information from and what method (e.g., email, magazine, etc.) is used. Please select all that apply.

	Conferences/Meetings	Email	Magazines/Newsletters	Podcasts	Social Media	Training courses	Webinars/Online learning
Federal Emergency Management Agency (FEMA)	☐	☐	☐	☐	☐	☐	☐
Fire Department Safety Officers Association (FDSOA)	☐	☐	☐	☐	☐	☐	☐
Fire Service Media or Fire Industry Journals	☐	☐	☐	☐	☐	☐	☐
International Association of Fire Chiefs (IAFC)	☐	☐	☐	☐	☐	☐	☐
International Association of Firefighters (IAFF)	☐	☐	☐	☐	☐	☐	☐
National Fallen Fire Fighters Association (NFFF)	☐	☐	☐	☐	☐	☐	☐
National Fire Academy	☐	☐	☐	☐	☐	☐	☐
National Fire Protection Association (NFPA)	☐	☐	☐	☐	☐	☐	☐
National Institute for Occupational Safety and Health (NIOSH)	☐	☐	☐	☐	☐	☐	☐
National Institute for Occupational Safety and Health (NIOSH) Fire Fighter Fatality Investigation and Prevention Program (FFFIPP)	☐	☐	☐	☐	☐	☐	☐
National Volunteer Fire Council (NVFC)	☐	☐	☐	☐	☐	☐	☐
Occupational Safety and Health Administration (OSHA)	☐	☐	☐	☐	☐	☐	☐
U.S. Fire Administration (USFA)	☐	☐	☐	☐	☐	☐	☐
Underwriters Laboratory (UL)	☐	☐	☐	☐	☐	☐	☐
Other (Specify_____________________)	☐	☐	☐	☐	☐	☐	☐

The NIOSH FFFIPP produces reports based on the firefighter fatality investigations it conducts. Do you know how to access the NIOSH LODD investigation reports?

☐ Yes

☐ No

☐ Don’t know

☐ Decline to respond

How often have you seen (heard about) a NIOSH LODD investigation report that describe recent firefighter fatalities and make recommendations for avoiding similar incidents?

☐ Receive email notification each time an investigation report is released

☐ Never [SKIP to Q17]

☐ Once or twice a year

☐ Several times a year

☐ Once a month or more

☐ Don’t know

☐ Decline to respond

Have you read any part of a NIOSH LODD investigation report in the last 12 months?

☐ Yes

☐ No [SKIP to Q13]

☐ Don’t know

☐ Decline to respond

Which sections of the NIOSH LODD investigation reports do you usually read? Please select all that apply.

☐ Executive Summary

☐ Introduction

☐ Fire Department

☐ Training and Experience

☐ Equipment and Personnel

☐ Building Construction

☐ Timeline

☐ Personal Protective Equipment

☐ Weather

☐ Investigation

☐ Recommendations

☐ References

☐ Appendix

☐ Don’t know

☐ Decline to respond

Thinking about each section of the NIOSH LODD investigation report, please provide us with your thoughts on the length of each section, and whether the length of the section should be modified.

	Eliminate entirely	Provide less detail	Keep current length	Provide more detail
Introduction	☐	☐	☐	☐
Fire Department	☐	☐	☐	☐
Training and Experience	☐	☐	☐	☐
Equipment and Personnel	☐	☐	☐	☐
Building Construction	☐	☐	☐	☐
Timeline	☐	☐	☐	☐
Personal Protective Equipment	☐	☐	☐	☐
Weather	☐	☐	☐	☐
Investigation	☐	☐	☐	☐
Recommendations	☐	☐	☐	☐
References	☐	☐	☐	☐
Appendix	☐	☐	☐	☐
Overall	☐	☐	☐	☐

NIOSH LODD investigation reports contain a timeline which presents the sequence of events as the department responded. Thinking about only the timeline, where would you prefer to see this information?

☐ Executive summary

☐ Main body of the investigation report

☐ Appendix

☐ Don’t know

☐ Decline to respond

The NIOSH LODD investigation reports sometimes reference other documents, such as fire service consensus standards, journal articles, standard operating procedures/guidelines, or more detailed technical reports. Do you usually have access to the additional documents that are referenced in the NIOSH investigation reports?

☐ Yes

☐ No

☐ Don’t know

☐ Decline to respond

NIOSH LODD investigation reports always include recommendations that are designed to help improve the health and safety of firefighters. Please indicate how much you agree or disagree with the following statements.

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
Recommendations are practical	☐	☐	☐	☐	☐
Recommendations are easy to understand	☐	☐	☐	☐	☐
Recommendations are specific and concrete	☐	☐	☐	☐	☐
Recommendations are useful to my department	☐	☐	☐	☐	☐

Do you receive NIOSH LODD-related information from your department?

☐ Yes

☐ No [SKIP to Q17]

☐ Don’t know

☐ Decline to respond

How is this information provided to firefighters? Please select all that apply.

☐ Company level training

☐ Copies of report summaries provided to firefighters

☐ Copies of reports provided to firefighters

☐ FD required individual training

☐ In-service training sessions

☐ Messages sent to firefighters by email

☐ Postings on bulletin boards

☐ Regular staff meetings

☐ Reports posted on department website

☐ Social media posts by the department or designated officer

☐ Summaries prepared by the department provided to firefighters

☐ Other (Specify _________________________)

☐ Don’t know

☐ Decline to respond

Please select the top three (3) ways you would prefer to receive information about NIOSH LODD investigation report recommendations. You may select up to three (3) options.

☐ CD/DVD

☐ Conference presentations or meetings

☐ Email

☐ In-person training sessions/classes

☐ NIOSH LODD Investigation Reports

☐ NIOSH website

☐ One-page fact sheets (i.e., infographics)

☐ Online self-paced training

☐ Pocket guides

☐ Podcasts

☐ Posters

☐ Social media posts

☐ Summary reports

☐ Other (Specify _________________________)

☐ Don’t know

☐ Decline to respond

CLOSING

Please provide any additional comments you may have for the NIOSH FFFIPP.

Thank you for your participation.

To access information about the NIOSH FFFIPP or to view the NIOSH LODD investigation reports go to: https://www.cdc.gov/niosh/fire/

Example 7: Implementation Assessment of NIOSH’s Workplace Violence Training and Development of Vignettes (could be adapted to determine implementation of any NIOSH developed training or education)

Purpose: This survey aims to gather feedback on how practitioners are using the training program, its effectiveness, and areas for improvement. Your insights will help us enhance the training experience by developing complementary training materials.

Shape1

Section 1: Participant Information

What is your job role?
- Manager
- Team Lead
- Specialist
- Practitioner
- Other (please specify): ___________
How long have you been in your current role?
- Less than 6 months
- 6 months to 1 year
- 1-3 years
- More than 3 years
Have you completed the training program?
- Yes
- No
- Partially

Shape2

Section 2: Utilization of the Training Program

How often do you use the skills and knowledge gained from the training program in your daily work?
- Daily
- Weekly
- Monthly
- Rarely
- Never
Which components of the training program do you find most useful? (Select all that apply)
- Theoretical content
- Practical exercises
- Case studies
- Group discussions
- Quizzes and assessments
- Other (please specify): ___________
How would you rate the relevance of the training content to your job role?
- Highly relevant
- Somewhat relevant
- Neutral
- Somewhat irrelevant
- Highly irrelevant
Have you applied any new techniques or strategies learned from the training program?
- Yes
- No
- If yes, please provide examples: ___________

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Section 3: Effectiveness of the Training Program

How confident do you feel in applying what you learned from the training?
- Very confident
- Somewhat confident
- Neutral
- Somewhat unconfident
- Very unconfident
Since completing the training, have you noticed any improvements in your work performance?
- Significant improvement
- Moderate improvement
- No noticeable change
- Slight decline
- Significant decline
What barriers, if any, do you face in applying the training to your work? (Select all that apply)
- Lack of time
- Lack of resources
- Lack of support from management
- Difficulty in understanding or implementing the content
- Other (please specify): ___________

Shape4

Section 4: Suggestions for Improvement

What aspects of the training program could be improved? (Select all that apply)
- Content relevance
- Delivery method
- Duration of the training
- Practical exercises
- Assessment methods
- Support and resources
- Other (please specify): ___________
Do you feel that additional training is needed to further develop your skills?
- Yes
- No
- If yes, please specify what kind of additional training would be beneficial: ___________
Please share any other feedback or suggestions you have regarding the training program:

Shape5

Shape6

Section 5: Overall Satisfaction

How satisfied are you with the overall training program?
- Very satisfied
- Satisfied
- Neutral
- Dissatisfied
- Very dissatisfied
Would you recommend this training program to a colleague?
- Yes
- No
- Maybe

Shape7

Section 6: Development and Dissemination of Complementary Workplace Violence Vignettes in Healthcare

There has been an interest in developing complementary vignettes to disseminate with this training. Vignettes are short, descriptive scenarios or stories used in research to elicit responses or to explore participants' attitudes, beliefs, and decision-making processes.

Examples of vignettes that can be used to explore various aspects of workplace violence in healthcare, including its causes, effects, and the strategies that can be employed to address it are outlined below. To assess the impact of a vignette on participants, we will use a combination of open-ended, Likert-scale, and multiple-choice questions. These questions should ascertain how the vignette influenced your thoughts, emotions, and potential actions as presented in the workplace violence training.

1. Verbal Abuse from Patients

Vignette:
A nurse is working a night shift in the emergency department. A patient, frustrated with the long wait time, begins to shout at the nurse, using derogatory language and making personal insults. The nurse remains calm and tries to explain the situation, but the verbal abuse continues, causing distress and anxiety for the nurse.