Attachment 5 - Instruction to Respondents for Completing Information Collection

Attachment 5 of Supporting Statement

Instructions to Respondents for Completing Information Collection

for

Evaluation of the Successful Business Strategies to Prevent Heart Disease and Stroke Toolkit

CDC Task Order Officer (TOO): Dyann Matson Koffman

National Center for Chronic Disease Control and Health Promotion

TOO Contact Information: 770-488-8002 (phone), 770-488-8151(fax)

Instructions Included in the Introductory E-mail Message:

Dear State Heart Disease and Stroke Prevention (HDSP) Program:

The American Institutes for Research (AIR), an independent, non-profit research organization, is conducting an evaluation for the Centers for Disease Control and Prevention (CDC), to assess how State Heart Disease and Stroke Prevention (HDSP) Programs (or Cardiovascular Health/CVH programs) work with employers to prevent heart disease and stroke among employees. This survey is being used to 1) collect information on your experiences with the CDC Toolkit on Successful Business Strategies to Prevent Heart Disease and Stroke and working with employer groups, 2) collect your feedback on the trainings and consultations provided to facilitate use of the Toolkit, and (3) identify revisions to the Toolkit so that it better meets your needs. This collection of data is permissible under Section 301 of the Public Heath Service Act (42 U.S.C. 241).

We are asking all 50 states and the District of Columbia to participate in this 20-question survey. It should take an average of 30 minutes to respond to the survey. You were selected to provide the information for your state because we believe that your position in the State or District of Columbia government makes you the most knowledgeable person about these issues. Your participation is entirely voluntary, and you will not be penalized for not participating, either in the information collection as a whole or for any particular question. We ask that only one representative from your State completes this survey and summarizes the experiences of your State as a whole. However, it is very important that we hear from everyone who has been selected, so that every state is represented and our findings are as accurate and representative as possible. Your responses will help us revise the Toolkit before it is more widely distributed.

The information you provide in the survey will be used by independent researchers working under contract with the CDC to evaluate the CDC’s Successful Business Strategies to Prevent Heart Disease and Stroke Toolkit. They will treat this information in a confidential manner, unless otherwise compelled by law. All survey results will be reported to the CDC and to you in the aggregate, without identifying individual States or respondents.

Please complete and submit the survey by [ENTER 2 WEEKS AFTER INTRODUCTORY E-MAIL SENT], and provide only one response per state. The first 25 states to complete the survey will receive an additional copy of the Toolkit. If you have any questions about this study or the content of the questionnaire please contact Margarita Hurtado, Ph.D. from the American Institutes for Research (AIR) at 301-592-2215 or at mhurtado@air.org. If you have concerns or questions about your rights as a participant, contact the Chair of AIR’s Institutional Review Board (which is responsible for the protection of project participants), Andrea S. Burling, Ph.D, toll free at 1-800-634- 0797 or at IRB@air.org.

Thank you for participating in this important survey. Your responses will help advance the goal of reducing heart disease and stroke in the United States!

Instructions Included In the Survey:

Please note that this survey was approved by the Office of Management and Budget:

Form Approved

OMB No. 0920-NEW

Exp. Date xx/xx/20xx________

Public Reporting Burden Statement

Public reporting burden of this collection of information is an average of 30 minutes per response. This estimate includes the time for reviewing instructions, searching existing data sources, and completing and reviewing the survey. 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, which is displayed on the first page of the survey instructions. 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, Georgia 30333; Attn: PRA (0920-NEW)

Use of the Survey Information

Completion of this survey is voluntary. The information you report here will be used by independent researchers at the American Institutes for Research (AIR), who are working under contract with the CDC to evaluate the CDC’s Successful Business Strategies to Prevent Heart Disease and Stroke Toolkit. They will treat this data in a confidential manner, unless otherwise compelled by law. All data will be reported to the CDC and to you in the aggregate, without identifying individual States or respondents. You may choose to answer this survey or not. If you choose not to do so, this will not affect your program’s funding.

Purpose of the Survey

This survey is being used to collect information on your experiences with the CDC Toolkit on Successful Business Strategies to Prevent Heart Disease and Stroke and working with employer groups. It also asks for your feedback on the trainings and consultations provided during 2006 and 2007 to facilitate your use of the Toolkit. The results for this survey will be used to make revisions to the Toolkit and to evaluate its dissemination and use. As part of the evaluation, they will be compared to responses to the survey conducted at the beginning of the evaluation. With your input, we will be able to develop an improved version of the Toolkit that can better serve you in your work with employers and health plans to prevent heart disease and stroke.

Before You Begin…

Instructions

This survey is a Web-based survey, so it can be completed at your convenience between the dates of XXX and XXX. Please have only one representative from your State complete the survey and summarize the experience of your State as a whole.

1. For questions with a set of answer choices, click with your mouse on the box corresponding to your choice and an “x” will appear. To change your answer, click again and the “x” will disappear. You can repeat the process to select a different answer.

2. For questions that have blank lines to write in your answer, click with your mouse right above the blank line in the grayed out space and start typing your answer. Please note that even though the space may look small, it will extend as you type.

2. When you are finished, click on the button on the final page. This will indicate that you have completed the survey and your responses will be submitted electronically to AIR researchers.

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