Form 0920-1050 Cancer Screening Change Package Evaluation Survey

Form approved

OMB # 0920-1050

Exp. date 06/30/2025

Appendix A: Cancer Screening Change Package Evaluation Survey

Hello! This survey is to gain information on your utilization of and thoughts about the Cancer Screening Change Package (CSCP). This survey will take no more than 10 minutes to complete.

1. Please choose which organization best represents where you work.

   1. State health department

   2. Federally Qualified Health Center (FQHC)

   3. Community Health Center

   4. Academia (i.e. university, college)

   5. Federal government

   6. Nonprofit

   7. Tribal

   8. Other _______

2. Please choose which position best describes your position.

   1. Chronic Disease Director

   2. State health department employee

   3. Physician

   4. Other clinical staff

   5. Community health worker

   6. Faculty member

   7. Patient Navigator

   8. Other __________

3. Have you visited the Cancer Screening Change Package (CSCP or Change Package) website?

   1. Yes

   2. No [Skip to question 18]

4. How did you hear about the Cancer Screening Change Package?

   1. This is my first-time hearing about it. [Skip to question 18]

   2. A colleague

   3. A meeting

   4. NACDD email

   5. Cancer Council

   6. Other: ________

5. Did you view or access the PDF format of the Change Package?

   1. Yes

   2. No [Skip to question 7]

   3. I did not see the PDF format of the Change Package [Skip to question 7]

6. Did you find the Change Package PDF content useful?

   1. Yes

   2. No

   3. Other: ___

7. Have you downloaded or utilized any tools and resources from the Cancer Screening Change Package (CSCP)?

   1. Yes

   2. No [Skip to question 10]

8. What tool(s) or resource(s) did you download? [essay]

9. Did you need to adapt the tool/resource you used to fit your own setting or needs?

   1. Yes, needed to adapt the tool(s) and was able to adapt it.

   2. Yes, needed to adapt but the tool(s) was not adaptable.

   3. No, it was not necessary to adapt.

10. Have you shared the Cancer Screening Change Package website link with others?

    1. Yes

    2. No [Skip to question 12]

    3. Other:

11. With whom have you shared the Cancer Screening Change Package with?

    1. Colleague at same institution

    2. Community Health Worker

    3. Health partner

    4. Other: _____

12. When visiting the Change Package website were you interested in tools or resources specific to a particular cancer type? [multiple option]

    1. Breast cancer

    2. Cervical cancer

    3. Colorectal cancer

    4. No, I did not search for a resource by cancer type.

13. Do you believe that having the tools and resources categorized by the organizational framework (i.e. change concept, change ideas, focus area) was helpful?

    1. Yes

    2. No

    3. Not sure

14. Did you search for tools or resources related to a particular focus area? [multiple option]

    1. Social Determinants of Health

    2. Individual and Community Awareness

    3. Community-Clinical Linkages

    4. Capacity Building for Providers and Staff

    5. Screening Policies, Procedures, and Practices within Health Facilities

    6. Follow-up and Referral

    7. No, I did not search for a resource by focus area.

    8. Not sure.

15. Do you find the CSCP intuitive to use?

    1. Yes

    2. No, why not _______

    3. Not sure, why not _____

16. Do you plan to access or use the CSCP?

    1. Yes

    2. No, why not _____ [Skip to question 20]

    3. Not sure, why not _____ [Skip to question 20]

17. What do you feel makes the CSCP unique in comparison to other resource hubs?: [essay]

18. Do you have any additional thoughts about the CSCP you would like to share?: [essay]

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1050).