Form 0917-0036 Public Health Nursing (PHN) Data Mart Survey Questions

Public Health Nursing (PHN) Data mart Survey

Form Approved

OMB Form No. 0917-0036

Expiration Date: (insert after approval)

The purpose of this survey is to determine knowledge and use of the Public Health Nursing (PHN) Data mart among PHNs, Director of PHNs and Consultant PHNs.

1. What is your age?

1. 18-19

2. 20-29

3. 30-39

4. 40-49

5. 50-59

6. 60 and above

2. What is your sex?

1. Male

2. Female

3. What is the highest level of education you completed?

1. Middle School

2. Some high school

3. High school

4. Some college

5. College

6. Post graduate

4. How many years of experience do you have as a PHN? _________

5. Do you know about the PHN Data mart?

1. Yes

2. No

6. Have you ever had any training on the use of the PHN Data mart?

1. Yes

2. No

7. Have you ever used the PHN Data mart?

1. Yes

2. No

If yes, how have you used the PHN data mart?

1. To obtain information about home visits

2. To supplement PHN program reports to management

3. To share PHN productivity reports at Tribal Consultation meetings

4. To support grant funding

5. To obtain information about PHN activity in support of Agency initiatives

6. To obtain information for a community assessment

7. Other

8. Has anyone offered you training on the PHN data mart?

1. Yes

2. No

Thank you

OMB BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 10 minutes per response including 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: Information Collection Clearance Officer, Indian Health Service, Office of Management Services, Division of Regulatory Affairs, 5600 Fishers Lane, Mail Stop 09E70, Rockville, MD 20857, RE: OMB Control No. 0917-0036. Please DO NOT SEND this form to this address.