Form 0917-0034 0917-0034-Sharing What Works - Best Practice, Promising

FORM APPROVED
OMB Approval No. 0917-0034
Exp. Date 11/30/2015

Indian Health Service

Sharing What Works – Best Practice, Promising Practice,

and Local Effort Form

The Indian Health Service (IHS) is creating an inventory of Best (i.e., Evidence-Based) Practice, Promising Practice, Local Effort (BP/PP/LE), Resources, and Policies occurring among American Indian/Alaska Native (AI/AN) communities, schools, work sites, health centers/clinics, and hospitals.

The purpose of this inventory is to:

• Assist our AI/AN communities with getting the information and health services they need;

• Form an IHS database of Best Practices, Promising Practices, Local Efforts, Resources, and Policies that can be easily accessed on the IHS website;

• Improve informed consultation with Tribal and Urban programs by facilitating transparency in IHS and IHS supported activities; and,

• Highlight the great work that occurs in the field.

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To submit a best practice, promising practice, local effort, resource, or policy, please complete the inventory form below. Your submission won’t be saved until you complete all the required fields and click the Submit button at the end of Step 3. At the end of the form, you will have an opportunity to preview and edit your submission before sending it to the database.

Public Burden Statement: In accordance with Paperwork Reduction Act (5 CFR 1320.8 (b)(3), a Federal 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. Respondents must be informed (on the reporting instrument, in instructions, or in a cover letter) the reasons for which the information will be collected; the way the information will be used to further the proper performance of the functions of the agency; whether responses to the collection of the information are voluntary, required to obtain a benefit (citing authority), or mandatory (citing authority); and the nature and extent of confidentiality to be provided, if any (citing authority). Public reporting burden for this collection of information is estimated to average 20 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the necessary data, and completing and reviewing the collection information. Send comments regarding the burden estimate or any other aspect of this collection of information to the IHS PRA Information Collection Clearance Staff, 801 Thompson Ave., Suite 450, Rockville, MD 20852.

* Indicates a Required Field

* 1. Please provide the name, title and contact information for the person filling in this template.

Name:	*
Site or location name:	*
Address 1:	*
Address 2:
City/Town:	*
State:	*
ZIP:	*
Country:
Email Address:	*
Phone Number:	*

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* 2. Should people reviewing your submission contact someone other than yourself for questions about the program?

Yes

No

By submitting this form you are agreeing that you or your designee can be contacted regarding this submission.

* 3. Please provide the contact information of the person the reviewer should contact:

Name:	*     (Required only if answer to Question 2 is yes)
Site or location name:
Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Country:
Email Address:	*     (Required only if answer to Question 2 is yes)
Phone Number:	*     (Required only if answer to Question 2 is yes)

* 4. What type of program or information are you submitting?

	Evidence-Based Practice:  Body of Evidence (usually based on more than a single program assessment) formally evaluated to be effective, or Best Practices, that can be replicated and implemented, even with modifications in other settings. Examples: USPHS Task Force or CDC Community Guide Recommendations.
	Promising Practice:  A single program that is evaluated with the results suggesting effectiveness and worthy of further study. Example: A community intervention project shown to reduce Type II Diabetes by 15%.
	Local Effort:  Programs and/or activities that have not been evaluated but are identified by local programs as producing positive results.
	Resources:  Information or materials that might help develop a program/project in a community. Examples: Grants and tool kits.
	Policy:  An ordinance, resolution, or law. Example: Community no smoking policy.

5. Please choose the service area, from the drop down list below, that best describes the location of the program or information you are submitting. A map of the 12 IHS service areas is below to help you with your selection.

National

Aberdeen

Alaska

Albuquerque

Bemidji

Billings

California

Nashville

Navajo

Oklahoma

Phoenix

Portland

Tucson

Other/Unknown

* 6. What is the Title of the program or information being entered?

* 7. Please define the project's target population: (check all that apply)

Infants (0-12 months) Toddler (12-24 months)

Children (2-11 years) Adolescent (12-17 years)

Adults (18-64 years) Elderly (65+ years)

* 8. Please describe the type of location where the project takes place: (check all that apply)

Community Clinic/Health Center	Hospital Home	School Work site
Other (please specify)

* 9. Please check the targeted health indicators impacted by the project. (Check all that Apply)
Note: Review of content is based partially on the Health Indicator(s) selected. Selecting more than one Indicator might require additional review; result in delay of approval, and publication of your submission for one Indicator before others.

Capacity Building and Assessment  Cardiovascular Disease  Diabetes  Disability  Environmental Health/Quality  Epidemiology and Statistics  Excessive Alcohol Consumption  Health Education

Healthcare Access  HIV/AIDS  Immunization  Infectious Disease  Information Technology  Injury Prevention  Maternal Child Health  Mental Health  Nutrition

Oral Health  Physical Activity  Sexually Transmitted Disease  Substance Abuse  Tobacco Use  Traditional Healing  Trauma Care  Violence  Zoonotic Disease (has animal link)

10. Please describe the project that you are submitting.

11. Please list the website where information about the program can be found (if applicable):

12. Please select at least one key word that would describe the project you are submitting. (Check all that apply)

Addictions  Advocacy  Alcohol/substance abuse prevention  Asthma  Behavioral health/behavioral change  Bonding/attachment  Breastfeeding  Cancer screening  Capacity building or empowerment  Child abuse/neglect  Child development  Chronic conditions  Coalition building  Community assessment  Community directed intervention  Community mobilization/organization  Depression  Dietary guidelines  Domestic violence prevention  Drug abuse prevention  DVPI  Environmental change  Falls  Family Planning  Food safety  Group process  Gynecology/obstetrics  Health literacy  Health promotion and wellness  Infant feeding  Interview and teaching strategies  Leadership

Lifestyle coaching  Methamphetamines  Motivation  Motor vehicle  MSPI  News and social media  Overweight and obesity  Parenting skills training  Pets/animals  Physical activity  Policy development and planning  Prenatal care  PTSD  Public Health intervention  School health  Scientific research  SDPI  Self-Care  Sexual assault  Staff training and credentialing  Sudden Infant Death Syndrome  Suicide prevention  Surveillance  Sustainability  Teaching strategies  Tobacco cessation  Traumatic Brain Injury  Veteran's health  Violence against women  Worksite health  Other(please specify)

Questions 13 to 14 are required in order to be considered evidence based practice or submission will be considered a promising practice or local effort upon evaluation unless materials are available for review.

* 13. Was the project evaluated?

Yes
No

* 14. Is the evaluation summary available?

Yes
No

* 15. Please specify a file or a set of files:

Accepted file types are: .doc, .pdf, .txt, .rtf

* If you are not able to upload your documents, or your documents are larger than 5 MB in size, you may send the evaluation materials one of the following ways:

Mail Address:
Indian Health Service
Attn: BPPPLE Team
801 Thompson Ave, Suite 300
Rockville, MD 20852

Fax: (301)594-6213, or (301) 443-7623
Attn: OSCAR Team

16. What is/was the overall cost (estimate) of the program?

 

17. Any final comments?