IHS CHR Survey submission form

Request for Approval under the “Generic Clearance for the Collection of
Qualitative Feedback on Agency Service Delivery”
(OMB Control Number: 0917-0036)

TITLE OF INFORMATION COLLECTION: Indian Health Service Impact Evaluation of
Community Health Representative (CHR) Program Web-based Survey
PURPOSE:
Kauffman & Associates, Inc. (KAI) is working on behalf of IHS to conduct a mixed methods
evaluation of the IHS Community Health Representative (CHR) program. The evaluation
includes a survey of CHRs who provide services within IHS service areas. The study will
examine the CHR perceptions of their experience and satisfaction of the potential impacts on
AI/AN health.
DESCRIPTION OF RESPONDENTS:
The respondents will be CHRs actively providing services, 18 years or older.
TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software
[ ] Focus Group

[ ] Customer Satisfaction Survey
[ ] Small Discussion Group
[X] Other: web-surveys

CERTIFICATION:
I certify the following to be true:
1. The collection is voluntary.
2. The collection is low-burden for respondents and low-cost for the Federal Government.
3. The collection is non-controversial and does not raise issues of concern to other federal
agencies.
4. The results are not intended to be disseminated to the public.
5. Information gathered will not be used for the purpose of substantially informing influential
policy decisions.
6. The collection is targeted to the solicitation of opinions from respondents who have
experience with the program or may have experience with the program in the future.
Name: __Dr. Aislinn Rioux_____
To assist review, please provide answers to the following question:
Personally Identifiable Information:
1. Is personally identifiable information (PII) collected? [ ] Yes [X] No
2. If Yes, will any information that is collected be included in records that are subject to the
Privacy Act of 1974? [ ] Yes [ ] No
3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No

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Gifts or Payments:
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to
participants? [ ] Yes [X] No
BURDEN HOURS
Category of Respondent

No. of
Participation
Respondents Time

Individuals

325

20 minutes

Annual
Burden
Hrs.
108.33

Totals
FEDERAL COST: The estimated annual cost to the Federal government is __$1,613.3______.
If you are conducting a focus group, survey, or plan to employ statistical methods, please
provide answers to the following questions:
The selection of your targeted respondents:
1. Do you have a customer list or something similar that defines the universe of potential
respondents and do you have a sampling plan for selecting from this universe?
[ ] Yes [ X] No
If the answer is no, please provide a description of how you plan to identify your potential group
of respondents and how you will select them?
The sample of CHRs will be drawn from nine out of twelve IHS areas and each draw will
account for a percentage of the sample which will be based on how many people are served
within those respective IHS areas (see figure below).
Total IHS Service
Population
100 people (100%)
Three of the IHS areas will not be included in this study as follows: Alaska – CHR programs in
Alaska are implemented independently from those in the lower 48 states; Tucson – Contact
information was not provided by IHS for this area and provided contractor with directive to not
include in the sample; and Headquarters – CHRs do not provide services in this area.
Contact information for CHR area representatives and some CHR program directors have been
accessed through IHS. These contacts will serve as the access point to CHRs who will
participate in the survey. A link to the survey will be emailed to CHR area representatives and
program directors with a request to disseminate the link to the CHRs in their areas and programs.
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Administration of the Instrument
1. How will you collect the information? (Check all that apply)
[X] Web-based or other forms of Social Media
[ ] Telephone
[ ] In-person
[ ] Mail
[ ] Other, Explain
2. Will interviewers or facilitators be used? [ ] Yes [X] No
Please ensure that all instruments, instructions, and scripts are submitted with the request.

Instructions for Completing Request for Approval under the “Generic
Clearance for the Collection of Qualitative Feedback on Agency Service
Delivery”
TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the
subject of the request (e.g., Comment card for soliciting feedback on xxxx).
PURPOSE: Provide a brief description of the purpose of this collection and how it will be used.
If this is part of a larger study or effort, please include a statement to that effect in your
explanation. Please include how the information will be used to improve services or the program.
DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or
groups for this collection of information. These groups must have experience with the program.
TYPE OF COLLECTION: Check one box. If you are requesting approval of other
instruments under the generic, you must complete a form for each instrument.
CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the
collection will be returned as improperly submitted or it will be disapproved. Provide the name
of the individual who is the lead contact and responsible for the collection.
Personally Identifiable Information: Provide answers to the questions. Note:
Agencies/Programs should only collect PII to the extent necessary, and they should only retain
PII for the period of time that is necessary to achieve a specific objective. If you request PII,
please ensure that you state the reason why it is being collected (i.e., in order to respond to
inquiries from the participants).
Gifts or Payments: If you answer yes to the question, please describe the incentive and provide
a justification for the amount.
BURDEN HOURS:
Category of Respondents: Identify who you expect the respondents to be in terms of the
following categories: (1) Individuals or Households; (2) Private Sector; (3) State, local, or Tribal
governments; or (4) Federal Government. Only one type of respondent can be selected per row.
No. of Respondents: Provide an estimate of the number of respondents.
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Participation Time: Provide an estimate of the amount of time required for a respondent to
participate (e.g. fill out a survey or participate in a focus group).
Burden: Provide the annual burden hours: Multiply the number of responses and the
participation time and divide by 60 (minutes).
FEDERAL COST: Provide an estimate of the annual cost (and description) to the Federal
Government. Please provide a brief break down of the costs, including wages for staff utilizing
OPM pay scale table. See https://www.opm.gov/policy-data-oversight/pay-leave/salarieswages/salary-tables/pdf/2015/GS_h.pdf
If you are conducting a focus group, survey, or plan to employ statistical methods, please
provide answers to the following questions:
The selection of your targeted respondents: Please provide a description of how you plan to
identify your potential group of respondents and how you will select them. If the answer is yes,
to the first question, you may provide the sampling plan in an attachment.
Administration of the Instrument: Identify how the information will be collected. More than
one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or
facilitators (e.g., for focus groups) used.
Submit all instruments, instructions, and scripts are submitted with the request.

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IHS CHR Evaluation Survey
Introduction
1. Are you currently a Community Health Representative (CHR)?
Yes
No
Yes – (continue with survey)
No – How long ago were you a CHR? _____ (skip to demographic questions, end survey)
2. How many years have you worked as a CHR? ___________
3. In the past month, what has been your main job as a CHR? (For example:
transporting patients to their health appointments, reminding patients about their
health appointments, conducting administrative duties in the IHS facility or the tribal
health offices) ___________________________________________
4. While serving as a CHR, which trainings or learning opportunities have you completed to
improve your skills as a CHR?
i. Please describe any required trainings that you have completed for your
role as a CHR. _____________________________
ii. Please describe any other trainings or learning opportunities that you
participated in to improve your skills as a CHR.____________________
iii. Please describe any learning opportunities that were not offered to you
and if offered, you feel would have helped you improve your skills as a
CHR._________________________________________
5. What skills do you currently have as a CHR? Select all that apply.
Health Services

One-on-One Interactions

Administrative Tasks

• Recognizing and treating
disease
• Providing First Aid or CPR
• Increasing client
knowledge of health
• Scheduling health services
for patients
• Helping clients access
services

• Protecting confidentiality
of clients
• Advocating for client
needs
• Working with youth
• Working with elders
• Visiting patients at home

• Managing data on patient
health service use
• Keeping notes on patient
conditions or services
provided
• Reporting data about
patient services provided
• Using electronic health
records
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6. Which Indian Health Service (IHS) Area do you provide services for? Select one. (Will use
map for this question with a drop-down list of the options below)
Portland, Billings, Great Plains, Bemidji, California, Phoenix, Navajo, Tucson,
Albuquerque, Oklahoma, Nashville
7. As of today, how many CHRs (including you) work in the tribal organization or
community for which you provide services for?
1-3
4-6
7-9
10-12
13-15
16 or more
8. Please think of your roles as a CHR over the last week. On average, how many
patients/clients did you spend 15 minutes or more providing services? Services can include
making home visits, providing transportation, providing treatment, reviewing case notes,
making phone calls to check in, etc. (If you are unsure, it may be helpful to review your
calendar, schedule, or electronic health record system to come up with your answer.)
_______________________

Overall Program Impact
9. We’d like to know how you feel about being a CHR. For each statement, select the
number on a scale from 1 to 5 that best fits how you feel. Please select only one number
for each statement.
Statement
No Impact
The level of impact my work as a
CHR has on American
1
Indian/Alaskan Native health is:
Explain your answer –
Statement
My role as a CHR allows
healthcare for the people in my
community to be:
Explain your answer Statement
The CHR program in my
community has:
Explain your answer –

High Impact
2

3

4

Not
Accessible
1

Completely
Accessible
2

3

4

No
Challenges
1

5

5

Many
Challenges
2

3

4

5

2

Statement
As a CHR, my role in the health
of my community makes:
Explain your answer –
Statement
Medical teams in other
programs and facilities I work
with are:
Explain your answer –
Statement
As a CHR, when I provide
services to my community, I
face:
Explain your answer –
Statement
The CHR services I provide
benefit the youth in my
community:
Explain your answer –
Statement
The CHR services I provide
benefit the elders in my
community:
Explain your answer –
Statement
As a CHR I work with other
programs in my community:
Explain your answer –
Statement

No
Difference
1

A Large
Difference
2

3

4

Not
Impacted
by My Role
1

Highly
Impacted by
My Role
2

3

4

No
Problems
1

2

3

4

2

3

4

No Impact

5

All of the
Time
2

3

4

None of
the Time
1

5

All of the
Time

Not at All
1

5

Many
Problems

Not at All
1

5

5

All of the
Time
2

3

4

5

High Impact
3

The level of impact the CHR
program has on other programs
in my community is:
Explain your answer -

1

2

3

4

5

10. What are the top three challenges that limit the positive impact of your CHR program?
•
•
•
•
•
•

•

CHRs need more skills or experience.
CHRs have a difficult workload.
CHRs need more resources, such as
computers, medical equipment, or
cellphone minutes.
Administrators of the CHR program
do not accept or understand what
CHRs do for patients.
Other health care workers do not
accept or understand what CHRs do
for patients.
CHRs do not receive consistent
training (or training is not available).

•
•
•
•
•
•

The CHR program in your
community does not work with CHR
programs in other communities.
CHR services are not reimbursed and
are not billable.
CHRs receive low wages.
There is high turnover among CHRs.
The CHR program needs more
qualified applicants.
The native community does not
know about the services that CHRs
offer.
Other (please specify): _________

CHR Impact

11. What services do you provide to your patients/clients? Will use slider scale of 0 to 100.

Provide access to medical services or
programs (e.g., doctor’s appointments,
medical procedures)
Provide access to non-medical services or
programs (e.g., Meals on Wheels, housing,
clothing, senior services, home maintenance)
Help clients become more involved in the
community
Help clients become more self-sufficient
(e.g., cook for themselves, bathe themselves,
leave the house)
Update case paperwork or keep notes on
patients

25%

50%

75%

100%

4

Listen to patients or support them in seeking
treatment (e.g., emotional support,
suggestions for feeling better)
Listen to or support patients’ family members
(e.g., emotional support, provide a break to a
caretaker)
Check in with patients after a hospital stay,
illness, or clinic visit
Measure height/weight, perform lab tests, or
take vital signs
Identify risks of harm to patients (e.g., poor
diet, risks of falling, sharp objects, abusive
family)
Attend community events or programs with
patients
Help patients understand the terms used by
their medical providers and feel empowered
to ask questions
Provide or coordinate transportation for
clients
Other (specify): ________________________
12. Where have you provided services over the past year? Mark all that apply.
General Category
Community health center
Service provider’s office
Center for recreation or community events
Home setting
Work or educational setting
Government site

Examples
Community health clinic, a clinic at your agency
or organization’s location, or Indian health facility
Doctor’s office, specialist’s office, hospital, or
private clinic
Community center, teen center, veteran’s center,
senior citizen center, pow wow or other type of
community events
Patient/client’s home, my home, shelter or safe
place for domestic violence, migrant camp,
public housing unit
Patient/client’s worksite, school, or tribal
college/university
Jail, court, or social service office

13. Typically, after a patients/client is provided medical care (for example: seen at a
doctor’s office, goes through a surgery, or visits the emergency room), is the CHR the
next person they see?
Yes
No
a. If yes, how often does this happen?
Always
Usually
Sometimes Rarely
Never
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14. How often do you reach out on behalf of your patients/clients for things like social
services, contact tribal service offices, etc.?
Always
Usually
Sometimes Rarely
Never
15. What types of health issues have your current or past patients/clients had? Select all
that apply.
o
o
o
o
o

o
o
o
o
o
o
o
o

Alzheimer’s disease/Dementia
Arthritis
Asthma
Breastfeeding
Cancer (specify type):
 All
 Breast
 Cervical
 Colorectal
 Leukemia/
Lymphoma
 Lung
 Mouth/Throat
 Ovarian/
Uterine
 Prostate
 Skin
 Stomach
Cardiovascular disease
Child health
Children with special heath care needs
Diabetes
Family planning
Gay/Lesbian/Bisexual/Transgendered
issues
Heart disease
High blood pressure

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

HIV/AIDS
Immunizations
Infant Health
Injuries
Lead poisoning
Low birth weight prevention/follow-up
Men’s health
Mental health
Nutrition
Obesity
Osteoporosis
Physical activity
Pregnancy/Prenatal care/postpartum
care
Premature birth/ prevention/follow-up
Sexual behavior
Stroke
Substance Abuse
Tobacco control
Tuberculosis
Violence Define: domestic/child/
Women’s health
Emergency response
Dental /Oral Health
Preventive Services
Other issues (specify):
__________________

16. Among your current or past patient/client panel, have you had to provide services that
respond to the opioid crisis? Yes
No
If you answered yes to (Among your current or past patient/client panel, have you had
to provide services that respond to the opioid crisis?), how often have you provided
these services within the past year?
Always
Usually
Sometimes
Rarely
Never

6

17. Among your current or past patient/client panel, have you had to provide services that
respond to mental health issues?
Yes
No
If you answered yes to (Among your current or past patient/client panel, have you had
to provide services that respond to mental health issues?), how often have you provided
these services within the past year?
Always
Usually
Sometimes
Rarely
Never
18. Activities of daily living are basic activities a person must perform during a normal day to
remain independent. These daily activities can include getting in and out of bed,
dressing, bathing, eating, walking, and using the bathroom. Do you provide Activities of
Daily Living (ADL) services for your patients/clients?
Yes
No
19. Do you see a need for services provided to patients/clients beyond those listed on
assignment sheets? Yes
No

Impact Exploration

20. Would you say you build relationships with your patients/clients?

Yes

No

a. do you notice a change in their behavior concerning their health? Yes
i. If yes, please explain the observed changes in behavior.

No

21. Once you have established a relationship with your patient/client,

b. do your patients/clients share more information? Yes

No

c. Do you feel your patients/clients are more receptive to services? Yes
22. Do you feel you understand tribal culture? Yes

No

No

23. Do you feel you are more effective in providing services as a CHR because you
understand tribal culture? Yes
No
a. If yes, please provide an example.

Demographics (We would like to understand the CHR workforce)
24. To which gender do you most identify?
Female
Male
Prefer to self-identify ______________________
Prefer not to answer
25. What is your current age? _______

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26. What is the highest level of education you have completed?
• High School Diploma/GED
• Associate Degree
• Some college
• Bachelor’s Degree
• Master’s Degree
• Professional Degree
• Doctoral Degree
• Other___________________
27. What race/ethnicity do you identify with? Please select one.
• American Indian
o Tribal Affiliation _________________
• Hawaiian/Pacific Islander
• Asian
• Hispanic or Latino (a)
• Black or African American
• White
• Other_____________________________

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Consent Form for the Indian Health Service Impact Evaluation Survey
Community Health Representative Program
Purpose of Study

The Indian Health Service (IHS) “is the principal federal health care provider and health advocate for Indian
people, and its goal is to raise their health status to the highest possible level.”
Community Health Representatives (CHRs) are a critical part of the Indian Health Service (IHS) public health
system. They link available health programs to American Indian and Alaska Native (AI/AN) patients and
communities particularly in very rural areas. The CHR is a unique concept for providing health care, health
promotion, and disease prevention services.
Kauffman & Associates, Inc. (KAI) is working on behalf of IHS to conduct a mixed methods evaluation of the IHS
community health representative (CHR) program. The survey was designed to support the impact evaluation of
CHRs who provide services within IHS service Areas. Questions in this survey are an attempt to capture
quantitative data related to the CHR program including aggregate demographic data, CHR program and CHR role
impact.
Participation and Confidentiality
As part of the study, CHRs are asked to complete a self-administered online survey about their opinions of the
impact the CHR program has had on the health of American Indians. Your participation is entirely voluntary. You
have the right to not answer any question that is asked and to decline to participate further at any point in the
survey. In addition, your relationship with IHS will not be affected by your decision to participate or not to
participate. To protect anonymity of respondents, data from all survey participants will be aggregated.
If you agree to participate in this project, you will take part in a 15-20-minute online survey. Your confidential
responses will be recorded into a database on a computer to be used for reference by KAI staff. The data you
offer will provide information to IHS about the impact of the CHR program.
If you have any questions regarding this project or your participation, please contact Dr. Aislinn Rioux, Lead
Evaluator, at (509) 789-0625 or aislinn.rioux@kauffmaninc.com.
Risks and Benefits
There are no known risks from taking part in this project. Two benefits to your participation in the project
include: (1) informing IHS about your thoughts on the CHR program; and (2) helping IHS create improved health
care services for American Indian communities by understanding program strengths and gaps.
Participant Costs and Compensation
There is no cost to participate in this interview with the exception of time.

Page 1 of 2

Consent to Participate in Project
I have read and reviewed the above information about this project. I hereby consent and voluntarily agree to
participate in an online survey about the CHR program conducted by Kauffman & Associates, Inc., on behalf of
IHS. By agreeing to participate, I am not waiving any legal claims, rights, or remedies.

Page 2 of 2

First Introductory Email
Dear [NAME],
My name is [NAME] and I am writing to inform you about an upcoming opportunity to share your
thoughts and opinions about the community health representative (CHR) program through an online
survey. The survey is part of a project that Kauffman & Associates, Inc., (KAI) is conducting on behalf of
the Indian Health Service (IHS) to learn more about the CHR program. You will receive the survey by
email in one week.
Your experience as a CHR is highly valuable and we would appreciate the opportunity to include your
thoughts and opinions.
If you have any questions, please do not hesitate to reach out to Dr. Aislinn Rioux, Lead Evaluator, at
509-789-0625.
Thank you for your consideration and time today. We look forward to your participation!
Sincerely,
[NAME]

Initial outreach email
Dear [NAME],
My name is [NAME] and I am writing to request your participation in a short, online survey. This survey
is part of a project that Kauffman & Associates, Inc. (KAI) is conducting on behalf of the Indian Health
Service (IHS) to learn more the Community Health Representative (CHR) program.
Given your experience as a CHR, KAI would greatly appreciate the opportunity to include you in this
effort. If you are interested in participating, please follow the link below to access the survey. An
informed consent will be provided for you to review and acknowledge receipt and agreement of your
voluntary participation. Once you have completed this step, the survey will automatically follow which
will take approximately 15 – 20 minutes to complete. The survey will be open for 30 days with a
scheduled close date of [DATE].
(Link to Survey)
If you have any questions, please do not hesitate to reach out to Dr. Aislinn Rioux, Lead Evaluator, at
509-789-0625.
Thank you for your consideration and time today. We look forward to your participation!
Sincerely,
[NAME]

Follow-up email
Dear [NAME],
My name is [NAME]
and I am following up about an email sent last week requesting your participation in an online survey.
The survey is part of a project that Kauffman & Associates, Inc. (KAI) is conducting on behalf of the
Indian Health Service (IHS) to learn more about the CHR program. Your experience as a CHR is highly
valuable and we would appreciate the opportunity to include your thoughts and opinions.
Please follow the link below to access the survey. An informed consent will be provided for you to
review and acknowledge receipt and agreement of your voluntary participation. Once you have
completed this step, the survey will automatically follow which will take approximately 15 – 20 minutes
to complete. The survey will be open for 15 more days with a scheduled close date of XXX.
(Link to Survey)
If you have any questions, please do not hesitate to reach out to Dr. Aislinn Rioux, Lead Evaluator, at
509-789-0625.
Thank you for your consideration and time today; we look forward to your participation!
Sincerely,
[NAME]

Final outreach email
Dear [NAME],
My name is [NAME] and I am reaching out one more time to invite you to participate in an online survey
to share your thoughts and opinions about the Community Health Representative (CHR) program. The
survey is part of a project that Kauffman & Associates, Inc. (KAI) is conducting on behalf of the Indian
Health Service (IHS) to learn more about the CHR program. Your experience as a CHR is highly valuable
and we would not want you to miss the opportunity to participate.
Please follow the link below to access the survey. An informed consent will be provided for you to
review and acknowledge receipt and agreement of your voluntary participation. Once you have
completed this step, the survey will automatically follow which will take approximately 15 – 20 minutes
to complete. The survey will be open for 5 more days with a scheduled close date of [NAME].
(Link to Survey)
If you have any questions, please do not hesitate to reach out to Dr. Aislinn Rioux, Lead Evaluator, at
509-789-0625.

Thank you for your consideration and time today; we look forward to your participation!
Sincerely,

Follow-up Phone Script
Good [Morning/Afternoon].
My name is [NAME] and I’m calling from Kauffman & Associates, Inc (KAI). a native-owned company, on
behalf of the Indian Health Service (IHS) about the Community Health Representatives (CHR) survey. The
survey was sent to CHRs and CHR program directors on (DATE). The survey is part of a project that KAI is
conducting on behalf of IHS to learn more about the CHR program.
We have not yet received your response and want to make sure that you have the opportunity to
participate. Would you like me to resend the survey to you by email?
If “Yes”:
• Great, can you provide your email address?
If “No”
• Would you like me to send you the survey by fax?
If “Yes”
o Great, can you provide your fax number?
If “No”
o Proceed to next line.
Thank you for taking the time to talk with me. If you have any questions, please feel free to contact me
at (insert phone number).
Have a great day. Good-bye.