Form 0920- Att F1_Coalition_Survey

Form Approved

OMB No. 0920-xxxx Exp. Date xx/xx/xxxx

Coalition Survey

Welcome to the 1017 Coalition Survey!

The CCC Coalition Survey is being conducted by Battelle at the request of the Centers for Disease Control and Prevention (CDC), Division of Cancer Prevention and Control (DCPC). The survey is part of a larger comprehensive evaluation of a pilot program (also known as the 1017 program) in which CDC awarded additional funds to 13 Comprehensive Cancer Control (CCC) programs to increase their focus on Policy, System, and Environmental (PSE) change strategies.

You have been asked to participate in this survey because of your membership in the PSE Workgroup working with the 1017 program in your state or tribe. This survey is expected to take 20 minutes to complete.

Please answer the survey questions to the best of your ability based on your personal knowledge and experience with the PSE Workgroup. If you would like to consult with other staff members on any of the question items, you may do so. You do not need to complete the survey in one sitting. Your survey answers are not final until you hit the “Submit” button.

An identification number will be assigned to your completed survey in order to link information for all members of the same PSE Workgroup. Additional data security procedures will be implemented to ensure that your answers are maintained in a secure manner and your responses are never linked to you personally. You may choose not to participate in this survey, or to terminate your involvement at any time, without any penalty to you or your program. Completion of the survey constitutes your consent to participate.

If you have any questions about this evaluation please contact Battelle’s study director Carlyn Orians at 206-528-3320, or CDC’s technical lead Angela Moore at 770-488-3094. If you have any questions about your rights as a research participant, please contact Chair, Battelle Institutional Review Board, at 1-877-810-9530, extension 500.

PROCEED TO SURVEY

1. Please select your organization/program/department from the list:

[List of all organizations that are members of the PSE Workgroup]

2. What is your job title?_____________________________

3. How long have you been in this position (in months)?_______________________

4. Please indicate what your organization contributes, or can potentially contribute, to the 1017 PSE Workgroup (Select as many as apply)

• Funding

• In-Kind resources (e.g., meeting space)

• Paid staff

• Volunteers and/or volunteer staff

• Data resources including data sets, collection & analysis

• Information/ feedback

• Specific health expertise

• Expertise in PSE change strategies

• Expertise other than health or PSE change

• Connections with community allies

• Connection with community decision makers

• Fiscal management (e.g. acting as fiscal agent)

• Facilitation/leadership

• Communication/ use of media to convey public health benefits of PSE change.

• IT/web resources (e.g. server space, web site development, social media)

5. What is your organization's most important contribution to the 1017 PSE Workgroup? (Select one)

(Same response choices as in Q4)

6. Outcomes of the 1017 PSE Workgroup’s efforts include (or could potentially include): (Select as many as apply)

• Improved communication/use of media

• Public awareness

• Community support

• Decision maker’s understanding of the issue

• Public policy changes

• Health care system changes

• Improved health outcomes

• Community environmental changes

• Reduction of health disparities

7. Which is the 1017 PSE Workgroup’s most important outcome? (Select one)

(Same response choices as in Q6)

8. How successful has 1017 PSE Workgroup been at reaching its goals? (Select one)

• Not Successful

• Somewhat Successful

• Successful

• Very Successful

• Completely Successful

9. What aspects of collaboration contribute to this success? (Select as many as apply)

• Bringing together diverse stakeholders

• Meeting regularly

• Exchanging information/knowledge

• Sharing resources

• Shared learning/technical assistance

• Informal relationships created

• Collective decision-making

• Having a shared mission, goals

10. In your opinion, does your PSE Workgroup have sufficient representation from groups, organizations, and/or schools in your community to accomplish the objectives of the PSE Workgroup? (Select one).

• No

• Yes

• Don’t know

11. There is general agreement with respect to the mission of the PSE Workgroup. (Select one)

• Strongly Disagree

• Disagree

• Agree

• Strongly Agree

• Don’t Know

12. There is general agreement with respect to the priorities of the PSE Workgroup (Select one)

• Strongly Disagree

• Disagree

• Agree

• Strongly Agree

• Don’t Know

13. There is general agreement with respect to the strategies the PSE Workgroup should use to pursue its priorities (Select one)

• Strongly Disagree

• Disagree

• Agree

• Strongly Agree

• Don’t Know

14. I can talk openly and honestly at PSE Workgroup meetings. (Select one)

• Strongly Disagree

• Disagree

• Agree

• Strongly Agree

• Don’t Know

15. I feel that I have a voice in what the PSE Workgroup decides. (Select one)

• Strongly Disagree

• Disagree

• Agree

• Strongly Agree

• Don’t Know

16. Overall, how comfortable are you with decision-making processes within the PSE Workgroup? (Select one)

• Not Comfortable

• Somewhat Comfortable

• Comfortable

• Very Comfortable

• Completely Comfortable

17. What are the main strategies your PSE Workgroup has used to address conflicts that occur? (Select two only)

• Open debate about opposing viewpoints

• Postponing or avoiding discussions of controversial issues

• Having a third party mediate between those with opposing viewpoints

• Having the opposing parties negotiate directly with each other

• One party to the conflict gives in

• Don’t know

18. From your organization’s perspective, how much do the benefits of participation in the PSE Workgroup outweigh the costs at this point? (Select one)

• The costs outweigh the benefits

• The benefits are roughly equal to the costs

• The benefits outweigh the costs

• Don’t know

19. From the list, select the organizations with which you have an established relationship (either formal or informal). You will be asked a set of questions about your relationship with each organization you select, in the context of the PSE Workgroup.

[List of all organizations that are members of the PSE Workgroup]

	Question	Partner 1	Partner 2	Partner 3…	…Partner 20
Network Interaction	Participating in the PSE Workgroup gave me the chance to begin a working relationship with this partner	Yes No	Yes No	Yes No	Yes No
	How frequently does your organization work with this organization on issues related to the 1017 PSE Workgroup goals?	Never- Once a year or less About once a quarter About once a month Every week Every day	Never- Once a year or less About once a quarter About once a month Every week Every day	Never- Once a year or less About once a quarter About once a month Every week Every day	Never- Once a year or less About once a quarter About once a month Every week Every day
	What kinds of activities does your relationship with this organization entail?	None Cooperative Activities Coordinated Activities: Integrated Activities:	None Cooperative Activities Coordinated Activities: Integrated Activities:	None Cooperative Activities Coordinated Activities: Integrated Activities:	None Cooperative Activities Coordinated Activities: Integrated Activities:
Strategic Value	How valuable is this organization's power and influence* to achieving the overall mission of the 1017 PSE Workgroup?	Not at all A small amount A fair amount A great deal	Not at all A small amount A fair amount A great deal	Not at all A small amount A fair amount A great deal	Not at all A small amount A fair amount A great deal
	How valuable is this organization's level of involvement** to achieving the overall mission of the 1017 PSE Workgroup?	Not at all A small amount A fair amount A great deal	Not at all A small amount A fair amount A great deal	Not at all A small amount A fair amount A great deal	Not at all A small amount A fair amount A great deal
	How valuable is this organization’s resource contribution*** to achieving the overall mission of the 1017 PSE Workgroup?	Not at all A small amount A fair amount A great deal	Not at all A small amount A fair amount A great deal	Not at all A small amount A fair amount A great deal	Not at all A small amount A fair amount A great deal
Trust	How reliable^ is the organization/program/department?	Not at all A small amount A fair amount A great deal	Not at all A small amount A fair amount A great deal	Not at all A small amount A fair amount A great deal	Not at all A small amount A fair amount A great deal
	To what extent does the organization share a mission^^ with the 1017 PSE Workgroup’s mission & goals?	Not at all A small amount A fair amount A great deal	Not at all A small amount A fair amount A great deal	Not at all A small amount A fair amount A great deal	Not at all A small amount A fair amount A great deal
	How open to discussion^^^ is the organization?	Not at all A small amount A fair amount A great deal	Not at all A small amount A fair amount A great deal	Not at all A small amount A fair amount A great deal	Not at all A small amount A fair amount A great deal

*Power/Influence: The organization holds a prominent position in the community by being powerful, having influence, success as a change agent, and showing leadership.

**Level of Involvement: The organization is strongly committed and active in the partnership and gets things done.

***Contributing Resources: The organization brings resources to the partnership like funding, information, or other resources.

^Reliable: This organization is reliable in terms of following through on commitments.

^^Mission Congruence: this organization/program/department shares a common vision of the end goal of what working together should accomplish.

^^^Open to Discussion: This entity is willing to engage in frank, open and civil discussion (especially when disagreement exists). The entity is willing to consider a variety of viewpoints and talk together (rather than at each other). You are able to communicate with this entity in an open, trusting manner.

Public reporting burden of this collection of information is estimated to average 20 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, GA 30333, ATTN: PRA (0920-xxxx).