SOTS Mock screenshots

Survey: BIC Module NEW QUESTIONS ONLY - COPIED
I. Infrastructure: Workforce
2. If YES, how long (in years) has the person been the injury program director?

3. How long (in years) has the person worked in the injury prevention field?

4. What type of training (or academic preparation) does the injury program director have? (Check all that apply).
Highest Education Attainment:
Bachelors degree
Graduate degree (e.g., MPH, MS, MPA, DrPH, PhD); NO graduate-level curriculum related to injury prevention
Graduate degree (e.g. MPH, MS, MPA, DrPH, PhD); graduate-level curriculum related to injury prevention

Trainings and/or Certifications:
No Training
Specific injury prevention training program/fellowship that is university-affiliated, sponsored by a professional association, and/or
sponsored by a federal government agency (e.g., Johns Hopkins Summer Institute, PREVENT violence prevention program, Indian Health
Service Program Development or Epidemiology fellowship, University of Michigan Summer Institute)
Professional development webinars, short trainings, mentoring, etc.
Other (please explain)

7. What type of training does the epidemiologist/statistician/data professional have? If you have more than one
person devoted to this role, please provide the highest level of training attained by any person in this role.
Graduate degree in epidemiology or biostatistics
Other graduate degree in a quantitative science, such as engineering, economics, demography, etc.
Other graduate degree, not-quantitatively related
Undergraduate degree (please explain)

10. What type of training does the program evaluator have? If you have more than one person devoted to this role,
please provide the highest level of training attained by any person in this role.
Graduate degree that included specific coursework in program evaluation, such as public health program evaluation, education, or policy
evaluation
Other graduate degree
Undergraduate degree (please explain)

11. Does your VIP program have access to staff support for communications ?
[If YES go to #12. If NO go to #14.]

Yes, within the VIP program
Yes, within the state health department
Yes, by consultant
Yes, by Injury Control Research Center
No
Other (please specify)

12.How many FTEs are devoted to VIP communication as a primary role?

Please note that a full time individual can serve multiple

roles, but his or her time cannot add up to more than 1.00 FTE. For example, if you already reported that one person is 1.00 FTE equivalent as programs/
interventions, you cannot report this same person as one FTE communications.

0.0 FTE
0.01-0.25 FTE
0.26-0.50 FTE
0.51-0.75 FTE

0.76-0.99 FTE
1.0, or equivalent to one FTE
More than 1.0, or equivalent to more than one FTE

13. What type of training does the communications staff have? If you have more than one person devoted to this role,
please provide the highest level of training attained by any person in this role.
Graduate degree that included training in health communication
Other graduate degree
Undergraduate degree (please explain)

14. Does your VIP program have access to staff support for policy work?
[If YES go to #15 If NO go to #17.]

Yes, within the VIP program
Yes, within the state health department
Yes, by consultant
Yes, by Injury Control Research Center
No
Other (please specify)

15.How many FTEs are devoted to VIP policy work as a primary role?

Please note that a full time individual can serve multiple roles, but

his or her time cannot add up to more than 1.00 FTE. For example, if you already reported that one person is 1.00 FTE equivalent as programs/ interventions,
you cannot report this same person as one FTE policy work.

0.0 FTE
0.01-0.25 FTE
0.26-0.50 FTE
0.51-0.75 FTE
0.76-0.99 FTE
1.0, or equivalent to one FTE
More than 1.0, or equivalent to more than one FTE

16. What type of training does the policy staff have? If you have more than one person devoted to this role, please
provide the highest level of training attained by any person in this role.
Graduate degree that included training in health policy, government, political science
Other graduate degree
Undergraduate degree (please explain)

17. Does your VIP program have access to staff support for programs/interventions?
[If YES go to #18. If NO go to #20.]

Yes, within the VIP program
Yes, within the state health department
Yes, by consultant
Yes, by Injury Control Research Center
No
Other (please specify)

18.How many FTEs are devoted to VIP programs/interventions as a primary role?

Please note that a full time individual can serve

multiple roles, but his or her time cannot add up to more than 1.00 FTE. For example, if you already reported that one person is 1.00 FTE equivalent as
communications, you cannot report this same person as one FTE programs/interventions.

0.0 FTE
0.01-0.25 FTE
0.26-0.50 FTE
0.51-0.75 FTE
0.76-0.99 FTE
1.0, or equivalent to one FTE
More than 1.0, or equivalent to more than one FTE

19. What type of training does the programs/interventions staff have? If you have more than one person devoted to
this role, please provide the highest level of training attained by any person in this role.
Graduate degree that included training in public health program implementation/behavioral sciences (Y/N)
Other graduate degree
Undergraduate degree (please explain)

II. Infrastructure: Funding
For each funding source, please indicate how long the funding has been available and how far into the future you have
a commitment of funding.
How long has this How far into the
funding
future do you have
continuously been a commitment of
available? [# of
funding? [# of
years]
years]
State General Revenue XTR
Dedicated State Funding Stream (e.g., fines and fees) XTR
State Highway Safety Office (e.g., Safe Routes to School) XTR
Other State Funding 1 XTR
Other State Funding 2 XTR
Other State Funding 3 XTR
CDC/NCIPC Integrated Core Injury Prevention and Control Program (Core State Injury and Violence
Prevention Program Grant Part A) XTR
CDC/NCIPC Traumatic Brain Injury Extended Surveillance Program (Core State Injury and Violence
Prevention Program Grant Part B) XTR
CDC/NCIPC Traumatic Brain Injury Emergency Department Surveillance Program (Core State Injury and
Violence Prevention Program Grant Part C) XTR
CDC/NCIPC Traumatic Brain Injury Service Linkage Program (Core State Injury and Violence Prevention
Program Grant Part D) XTR
CDC/NCIPC Older Adult Falls Program (Core II) XTR
CDC/NCIPC Child Injury Prevention Program (Core II) XTR
CDC/NCIPC Teen Dating Violence Initiative (Core II) XTR
CDC/NCIPC Core VIPP Base Integration Component (BIC) XTR
CDC/NCIPC Core VIPP Regional Network Leader (RNL) XTR
CDC/NCIPC Core VIPP Surveillance Quality Improvement (SQI) XTR
CDC/NCIPC Core VIPP Motor Vehicle Injury Prevention XTR
CDC/NCIPC Core VIPP Falls Among Older Adults XTR
CDC/NCIPC National Violent Death Reporting System (NVDRS) XTR
CDC/NCIPC – Rape Prevention and Education (RPE) XTR
CDC/NCIPC Domestic Violence Prevention Enhancement and Leadership Through Alliances (DELTA) XTR
CDC/NCIPC Residential Fire-related Injury Prevention Program XTR
CDC – Preventive Health and Health Services (PHHS) Block Grant XTR
CDC – Communities Putting Prevention to Work XTR
Consumer Product Safety Commission (CPSC) XTR
Federal Emergency Management Agency (FEMA) XTR
HRSA/MCHB – Title V Block Grant XTR
HRSA/MCHB – Emergency Medical Services for Children (EMSC) XTR
National Highway Traffic Safety Administration (NHTSA) CODES XTR
National Highway Traffic Safety Administration (NHTSA) Other XTR
Substance Abuse and Mental Health Services Administration (SAMHSA) Campus Suicide Prevention
Grants XTR
Substance Abuse and Mental Health Services Administration (SAMHSA) State and Tribal Youth Suicide
Prevention Grants XTR
U.S. Department of Justice XTR

U.S. Department of Transportation (Federal, not through the state DOT or State Highway Safety
Office) XTR
Other Federal Funding 1 XTR
Other Federal Funding 2 XTR
Other Federal Funding 3 XTR
Corporate/Private XTR
Foundation XTR
Nonprofit Organizations (i.e., Safe Kids, Public Health Institutes, etc) XTR
Universities XTR
Other 1 XTR
Other 2 XTR
Other 3 XTR
Other 4 XTR

21.Please tell me about plans that are currently in place to sustain your VIP program’s efforts. Is the diversification
of funding sources considered a strategy for sustainability? If so, how?

IV. Surveillance: Uses of Core Datasets
26.Considering all of the datasets we just discussed, in which of the following ways do you use surveillance data?
(Check all that apply.)
YES

NO

a.To inform policy
b.To determine the effectiveness of
programs
c.To do cost analysis
d.To inform decisions about planning injury
and violence prevention initiatives

27. Do you have a systematic way of selecting your priorities using surveillance data?
YES
NO

28. Which of these do you use when setting priorities? [select all that apply]
High morbidity rates
High mortality rates
Cost of injury
Disparities across population groups
Trend analysis
Other

V. Surveillance: Dissemination of Surveillance Data
30. If your program developed data reports or summaries, what types of reports or summaries were produced? (Check
all that apply)
Fact sheets for the public and/or policy makers

Frequencies/Descriptive data about injury problems
Narratives interpreting data
Narratives outlining case reports about injured individuals
Publications in peer-reviewed journals
Presentations at conferences and workshops
Posters at conferences and workshops
Cost of injury reports
Disparities among population groups or regions
Reports with analytic measures (for example, Odds Ratio, Confidence Intervals, regression analyses)
Regression/Trend Analysis

31. Were these reports disseminated?
YES [Go to #32.]
NO [Go to #35.]

32. To whom were these reports disseminated? (Check all that apply.)
ICRCs or other academic centers
Local public health depts.
Through peer-reviewed publications
VIP programs in other states
ICPG members
State health dept leadership
Other stakeholders

33. For reports distributed…
YES
a. Was there any discussion with these partners/stakeholders about the reports?
b. Were any next steps/action items identified from the reports?

34. If next steps were identified, please explain.

The following next sections are going to ask about your strategies, evaluation
activities, and partnerships within each Year 1 BIC Focus Areas for your state.
VII. Evaluation: Uses Evaluation Findings
VIII. Evaluation: Disseminates Evaluation Findings
36. In the past year, did your program evaluate any strategies in ${custom19}?
YES [Go to i]
NO [Go to #45.]

37. Did any evaluation findings result in policy/programmatic improvements within ${custom19}?
We reviewed evaluation findings AND made policy/programmatic changes
We reviewed evaluation findings, BUT DID NOT make policy/programmatic changes
We DID NOT review evaluation findings for policy/programmatic changes

40. If YES, What types of evaluation reports or summaries were produced? (Check all that apply)
Summary reports including data and narrative information
Final report to funder
Brief summary report in a newsletter/regular communication
Present evaluation findings during webinars/group conference calls
Publications in peer-reviewed journals
Presentations at conferences and workshops

NO

Posters at conferences and workshops
Other: please specify

41. Were any evaluation reports or summaries disseminated?
YES [Go to #42.]
NO [Go to #45.]

42. To whom were these reports distributed?
ICRCs or other academic centers
Local public health depts.
Through peer-reviewed publications
VIP programs in other states
ICPG members
State health dept leadership
Other stakeholders
Webinar/conference call attendants
Conference attendants

43. For reports distributed…
YES [If YES, go to #44.]

NO [If NO, go to #45.]

a. Was there any discussion with these partners/stakeholders about the reports?
b. Were any next steps/action items identified from the reports?

44. If yes, please explain.

IX. Collaboration
We are interested to know what other partners may have provided resources – either financial or in-kind -- to assist
you in promoting or implementing work in each of your BIC focus areas. Please focus on partners that enable you to
do things you would not have been able to do on your own, and/or significantly expanded the reach of your program.
Review of ${custom1} Annual Progress report shows that you listed the following partners/collaborators for your
work in ${custom19}:
${custom26}
${custom27}
${custom28}
${custom29}
${custom30}
${custom31}
${custom32}
${custom33}
${custom34}
${custom35}
${custom36}
${custom37}
${custom38}
${custom39}
${custom40}

45. Please confirm that this list is complete and representative of your collaborations and partnerships for
${custom19} in Year 1:
YES, this is a complete list. [Go to # 46.]
NO, this is not a complete list: [Go to i]

i. If this is not a complete list, please enter in the name of the partnerships/collaboration that are not represented in
the list above. Also note here if one of the partners listed above should be removed from the list.
Additional Partners:
Partners to be Removed:
Considering your list of partners, please list your top three (3) collaborations and partnerships for your work in
${custom19} in Year 1.
Partner #1:
Partner #2:
Partner #3:
46. Still thinking about your top organizations with which you partnered for your ${custom19}, tell us what type of
assistance partner organizations provided. Please select all that apply.
Partner #1

Partner #2

Partner #3

Cash support (i.e. leveraging funds)
Staff time for planning or implementing initiative
Loan of facilities or vehicles or equipment
Publicity through mailings, listserv
Safety equipment to give away (e.g., smoke alarms, gun locks)
Access to experts for training staff
Access to experts for direct intervention with participants
Contacts with other partners for fundraising efforts
Contacts with other partners for advocacy efforts
Printing materials, making supplies, or structures
Making data available for planning or evaluation
Assisting with data analysis for planning or evaluation
Assisting with disseminating results
Provides access to target population

47. Considering all the resources (funding and other resources) needed for ${custom19}, please select the description
from the list below that most accurately describes your work with partners for this focus area: (Choose one)
The VIP program is the primary program implementer
The VIP program and its partners are equal collaborators in program implementation
The partners are the primary program implementers