002_CAAI_State Sys 002_CAAI_State Systems

Attachment I
Network Questionnaire

OMB Number: XXXX-NEW
Expiration Date
Public Burden Statement: 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. The OMB control
number for this project is XXXX-XXXX. Public reporting burden for this collection of information is
estimated to average ____ minutes per respondent annually, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports
Clearance Officer, 5600 Fishers Lane, Room 14-33, Rockville, Maryland, 20857.

State:____________________________
GRANTEE NETWORK: AS OF [DATE]
For a network analysis of your grant program we ask you to complete the Network Diagram on the
following page.
1. Enter the names of all organizations you, the grantee, consider to be partners in the
implementation of grant activities.
2. Indicate the frequency of communication between the grantee and each partner.
Communication can be either by telephone, email, or written reports, but the content of the
communication must be regarding grant activities. Use the codes described below.
If communication between the grantee and
the partners is at least:
Weekly

Indicate this level by drawing the following
type of line:
(single thick line)

Twice a month

(double thin line)

Monthly

(single thin line)

Quarterly

(dashed line)

Twice a year

(dotted line)

Yearly

(no line)

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NETWORK OF THE STATE IMPLEMENTATION GRANT: AS OF [DATE]

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State:______________________

3. Check the type of relationship the grantee has with each partner regarding grant
activities. The definitions for the Relationship Types appear below this table. These
definitions are from Taylor‐Powell, Ellen, Boyd Rossing, and Jean Geran. “Evaluating
Collaboratives.” University of Wisconsin‐Extension, Madison, Wisconsin. July 1998.
Type of Relationship
Partner

Communication

Contribution

Coordination

Cooperation

Collaboration

Communication = The grantee and this partner discuss issues and share information about each
other’s activities. The relationship is at the stage of developing a common
understanding and exploring common ground.
Contribution =

The exchanges between the grantee and this partner are about supporting
each other’s efforts. The relationship is at the stage of building mutual
obligations and trust.

Coordination =

The grantee and this partner are coordinating needs, resources, and activities.
The relationship is at the stage where both parties are adjusting current
activities for more efficient and effective results.

Cooperation =

The grantee and this partner are linking resources to help both organizations
achieve joint goals. The relationship is at the stage of building trust by
working together.

Collaboration = The grantee and this partner have developed a shared vision for the system.
The relationship is at the stage of sharing resources to build an
interdependent system.

State:________________________

3. Report in the table below current external factors that are facilitating the
implementation of grant activities and those that are delaying or preventing
implementation. External factors can be at the federal, state, region, or local levels.
Examples include economic conditions, policy changes, a partner’s financial condition,
changes in key agency personnel, provider workforce issues, school or early intervention
programs, or changing population patterns.
Current External Factors That Are:
Facilitating Grant Activities

Delaying or Preventing Grant Activities

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