Private sector, State, and Local Partners

PARTNER DEFAULT (Customizable) Survey Questions

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OMB No. 0990-NEW

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1	Please select your organization/program/department from the list:
2	What is your job title?
3	How long have you been in this position (in months)?
4	Please indicate what your organization/program/department contributes, or can potentially contribute, to this community collaborative (choose as many as apply).	Funding In-Kind Resources (e.g., meeting space) Paid Staff Volunteers and Volunteer staff Data Resources including data sets, collection and analysis Info/ Feedback Specific Health Expertise Expertise Other Than in Health Community Connections Fiscal Management (e.g. acting as fiscal agent) Facilitation/Leadership Advocacy IT/web resources (e.g. server space, web site development, social media)
5	What is your organization's most important contribution to this community collaborative?	Same as #4
6	Outcomes of this community collaborative's work include (or could potentially include): (choose all that apply).	Health education services, health literacy, educational resources Improved services Reduction of Health Disparities Improved Resource Sharing Increased Knowledge Sharing New Sources of Data Community Support Public Awareness Policy, law and/or regulation Improved Health Outcomes Improved communication
7	Which is this community collaborative's most important outcome?	Same as #6
8	How successful has this community collaborative been at reaching its goals?	Not Successful Somewhat Successful Successful Very Successful Completely Successful
9	What aspects of collaboration contribute to this success? (Choose all that apply)	Bringing together diverse stakeholders Meeting regularly Exchanging info/knowledge Sharing resources Informal relationships created Collective decision-making Having a shared mission, goals
10	From the list, select organizations/programs/departments with which you have an established relationship (either formal or informal). In subsequent questions you will be asked about your relationships with these organizations/programs/departments in the context of this community collaborative.
11	How frequently does your organization/program/department work with this organization/program/department on issues related to this community collaborative's goals?	Never/We only interact on issues unrelated to the collaborative Once a year or less About once a quarter About once a month Every week Every day
12	What kinds of activities does your relationship with this organization/program/department entail [note: the responses increase in level of collaboration]?	None Cooperative Activities: involves exchanging information, attending meetings together, and offering resources to partners (Example: Informs other programs of RFA release) Coordinated Activities: Include cooperative activities in addition to intentional efforts to enhance each other's capacity for the mutual benefit of programs. (Example: Separate granting programs utilizing shared administrative processes and forms for application review and selection.) Integrated Activities: In addition to cooperative and coordinated activities, this is the act of using commonalities to create a unified center of knowledge and programming that supports work in related content areas. (Example: Developing and utilizing shared priorities for funding effective prevention strategies. Funding pools may be combined.)
13	How valuable is this organization/program/department's power and influence to achieving the overall mission of this community collaborative? *Power/Influence: The organization/program/department holds a prominent position in the community be being powerful, having influence, success as a change agent, and showing leadership.	Not at all A small amount A fair amount A great deal
14	How valuable is this organization/program/department's level of involvement to achieving the overall mission of this community collaborative? *Level of Involvement: The organization/program/department is strongly committed and active in the partnership and gets things done.	Not at all A small amount A fair amount A great deal
15	How valuable is this organization/program/department/s resource contribution to achieving the overall mission of this community collaborative? *Contributing Resources: The organization/program/department brings resources to the partnership like funding, information, or other resources.	Not at all A small amount A fair amount A great deal
16	How reliable is the organization/program/department? *Reliable: this organization/program/department is reliable in terms of following through on commitments.	Not at all A small amount A fair amount A great deal
17	To what extent does the organization/program/department share a mission with this community collaborative's mission and goals? *Mission Congruence: this organization/program/department shares a common vision of the end goal of what working together should accomplish.	Not at all A small amount A fair amount A great deal
18	How open to discussion is the organization/program/department? *Open to Discussion: this organization/program/department is willing to engage in frank, open and civil discussion (especially when disagreement exists). The organization/program/department is willing to consider a variety of viewpoints and talk together (rather than at each other). You are able to communicate with this organization/program/department in an open, trusting manner.	Not at all A small amount A fair amount A great deal
19+	Any number of open-ended or multiple choice questions can be added after #18.

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