Form 4 Core VIPP Non-Funded SHD: SOTS Financial Module

Attachment E-2

2011 SOTS Financial Module

Non-Funded State Health Department

Form Approved

OMB No. 0920-XXXX

Exp. Date:

Public Reporting burden of this collection of information is estimated at 60 minutes per response, including the 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 CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-XXXX).

Note to OMB: This document was developed in Survey Monkey. This MS Word version is a conversion from PDF format, thus some formatting errors may have occurred.

Thank you for agreeing to complete the Safe States Alliance 2011 State of the States (SOTS) Finance & Personnel Survey. The SOTS survey is administered to each U.S. state health department injury and violence prevention (IVP) program to develop a comprehensive picture of the status of these programs over time. The SOTS Finance & Personnel Survey is intended to help us better understand how states finance their injury and violence prevention programs and strengthen our ability to advocate, such as improving our ability to quickly quantify the potential impact of losses in particular sources of funding. The information collected through this survey will: Be used to generate an annual report on the state of injury and violence prevention programs in the U.S.; Provide the fourth year of data for measuring changes in these injury and violence prevention programs over time; Inform partners at the federal, national, state and local levels about the activities in the states or nation; Be used by Safe States to share in-depth information with state directors about possible program funding sources; and Help Safe States develop future programs and services to support our members. We know your time is valuable. In designing and testing this survey, Safe States has made every effort to limit the questions to those most essential in developing a profile of state IVP programs. Depending on the size and breadth of your program, it will take approximately X hours to gather the needed information and complete this questionnaire. Most data collected will be presented in aggregate. If you have any questions about the questionnaire, please contact Jamila Porter at 770-690-9000 or jamila.porter@safestates.org. Thank you for your contribution to this important and exciting project! Background

2011 SOTS Finance & Personnel Survey

The 2011 State of the States (SOTS) Finance & Personnel Survey asks for information about several aspects of your state's injury and violence prevention program funding sources and personnel. Please answer the questions based on the status of your program during Federal Fiscal Year 2011 (October 1, 2010 ­September 30, 2011). You may find it helpful to first review the hard copy of the survey (emailed to your State Representative) in order to gather all necessary information before beginning the survey. You also may find it helpful to coordinate completion of the survey among your staff by distributing hard copies of the staffing section and other portions of the survey to appropriate staff members who are most knowledgeable about the specific topics addressed. There are several ways to complete the survey: • Complete the entire survey online through Survey Monkey; • Complete the survey in hard copy first, then enter all responses online through Survey Monkey; OR • Complete the entire survey in hard copy and fax (770-690-8996) or email it (info@safestates.org) to Safe States for data entry. If you cannot use one of these methods to complete the survey, please contact Jamila Porter at Safe States (770-690­9000) to identify an alternative arrangement. If you choose to complete the survey online, you will be able to save your responses to allow you to complete the survey over several days or weeks. Your responses are saved when you click on the "next" button at the bottom of each page of the survey. You can access the survey to continue or edit your previous responses by using the same computer each time. When you re-access the survey, you will begin on the last completed page (not the beginning of the survey). If you try to complete the remainder of the survey using a different computer, you will not see any of your previous data. Additional notes about the survey: • Throughout the questionnaire, the acronym IVP is used to indicate "injury and violence prevention." • The intent of this survey is to assess the program within the state health department that is considered the PRIMARY or CENTRAL FOCUS of IVP activities. In completing the questionnaire, please focus your responses on the one program that is considered the PRIMARY or CENTRAL IVP program --whether the focus is on unintentional injury, intentional injury (violence), or both. In some states, however, there simply is no central IVP program. Perhaps there is no funding or personnel, or prevention activities may be spread among programs and units with no coordinating program or staff. Regardless of how your program is defined, the individual or program charged with program planning, strategic planning and/or policy development for IVP should answer the questions to the best of their ability based on what is considered to be the PRIMARY or CENTRAL FOCUS of your state’s IVP activities. If you have any questions or concerns about how to define the boundaries of your state's program, please contact Jamila Porter at 770-690-9000 jamila.porter@safestates.org to discuss. Clarification before completing the questionnaire will help ensure that the data collected are comparable across states.

2011 SOTS Finance & Personnel Survey

1. For the Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), what is the TOTAL NUMBER OF STAFF POSITIONS in your IVP program (including currently vacant positions)? NOTE: Please include part-time positions using the formula found at http://www.hr.tcu.edu/3163.htm (i.e., if you have two (2) full-time staff and one (1) 0.5 FTE, your response would be "2.5") Total Program Staff *

2011 SOTS Finance & Personnel Survey

1. You have indicated that you had [Q3] staff in Federal Fiscal Year 2011. Please indicate how many staff members were part of the IVPP in each of the following status categories. Your total answer should not exceed [Q3]. Staff Detail * Paid staff member (Full­time) Paid staff member (Part­time) Paid intern Unpaid intern Fellow Other

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from your State's General Revenue Fund? State General Revenue Fund * YES, I received funding from my State's General Revenue Fund. NO, I did NOT receive funding from my State's General Revenue Fund.

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from your State General Revenue Fund. 2. Please describe the source of the state general fund dollars (i.e., general state budget, speeding ticket fines, tobacco taxes, vanity license plate fees, etc.). 2 of 6 --State General Revenue Fund Confirmation * * State General Revenue Fund

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q10]? 2. Approximately what percentage of funding from the [Q10] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q10] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q10] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --State General Revenue Fund: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q10]? 4 of 6 --State General Revenue Fund: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from your Dedicated State Funding Stream (e.g., fines and fees)? Dedicated State Funding Stream * YES, I received funding from the Dedicated State Funding Stream. NO, I did NOT receive funding the Dedicated State Funding Stream.

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q21]? 2. Approximately what percentage of funding from the [Q21] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q21] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q21] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --Dedicated State Funding Stream: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q21]? 4 of 6 --Dedicated State Funding Stream: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from your State Highway Safety Office (e.g., Safe Routes to School)? State Highway Safety Office * YES, I received funding from the State Highway Safety Office. NO, I did NOT receive funding the State Highway Safety Office.

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from your State Highway Safety Office. 2 of 6 --State Highway Safety Office Confirmation * State Highway Safety Office

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q31]? 2. Approximately what percentage of funding from the [Q31] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q31] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q31] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --State Highway Safety Office: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q31]? 4 of 6 --State Highway Safety Office: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the CDC/NCIPC Integrated Core Injury Prevention and Control Program (Core State Injury and Violence Prevention Program Grant Part A)? CDC/NCIPC Integrated Core Injury Prevention Program (Core State IVP Program... * YES, I received funding from the CDC/NCIPC Integrated Core Injury Prevention and Control Program. NO, I did NOT receive funding from CDC/NCIPC Integrated Core Injury Prevention and Control Program.

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the CDC/NCIPC Integrated Core Injury Prevention and Control Program (Core State IVP Program Grant Part A). 2 of 6 --CDC/NCIPC Integrated Core Injury Prevention and Control Program * CDC/NCIPC Integrated Core Injury Prevention and Control Program

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q40]? 2. Approximately what percentage of funding from the [Q40] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q40] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q40] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CDC/NCIPC Integrated Core Injury Prevention and Control Program: ... * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q40]? 4 of 6 --CDC/NCIPC Integrated Core Injury Prevention and Control Program: ... *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the CDC/NCIPC Traumatic Brain Injury Extended Surveillance Program (Core State IVP Program Grant Part B)? CDC/NCIPC Traumatic Brain Injury Extended Surveillance Program (Core State ... * YES, I received funding from CDC/NCIPC Traumatic Brain Injury Extended Surveillance Program. NO, I did NOT receive funding from CDC/NCIPC Traumatic Brain Injury Extended Surveillance Program.

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the CDC/NCIPC Traumatic Brain Injury Extended Surveillance Program (Core State IVP Program Grant Part B). 2 of 6 --CDC/NCIPC Traumatic Brain Injury Extended Surveillance Program Co... * CDC/NCIPC Traumatic Brain Injury Extended Surveillance Program

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q49]? 2. Approximately what percentage of funding from the [Q49] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q49] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q49] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CDC/NCIPC Traumatic Brain Injury Extended Surveillance Program: ... * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q49]? 4 of 6 --CDC/NCIPC Traumatic Brain Injury Extended Surveillance Program: ... *

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the CDC/NCIPC Traumatic Brain Injury Emergency Department Surveillance Program. 2 of 6 --CDC/NCIPC Traumatic Brain Injury ED Surveillance Program Confirma... * CDC/NCIPC Traumatic Brain Injury Emergency Department Surveillance Program

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q58]? 2. Approximately what percentage of funding from the [Q58] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q58] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q58] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CDC/NCIPC Traumatic Brain Injury ED Surveillance Program: Fundin... * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q58]? 4 of 6 --CDC/NCIPC Traumatic Brain Injury ED Surveillance Program: Number... *

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the CDC/NCIPC Traumatic Brain Injury Service Linkage Program. 2 of 6 --CDC/NCIPC Traumatic Brain Injury Service Linkage Program Confirma... * CDC/NCIPC Traumatic Brain Injury Service Linkage Program

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q67]? 2. Approximately what percentage of funding from the [Q67] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q67] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q67] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CDC/NCIPC Traumatic Brain Injury Service Linkage Program: Fundin... * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q67]? 4 of 6 --CDC/NCIPC Traumatic Brain Injury Service Linkage Program: Number... *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the CDC/NCIPC Older Adult Falls Program (Core II)? CDC/NCIPC Older Adult Falls Program (Core II) * YES, I received funding from the CDC/NCIPC Older Adult Falls Program (Core II). NO, I did NOT receive funding from the CDC/NCIPC Older Adult Falls Program (Core II).

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the CDC/NCIPC Older Adult Falls Program. 2 of 6 --CDC/NCIPC Older Adult Falls Program Confirmation * CDC/NCIPC Older Adult Falls Program

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q76]? 2. Approximately what percentage of funding from the [Q76] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q76] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q76] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CDC/NCIPC Older Adult Falls Program: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q76]? 4 of 6 --CDC/NCIPC Older Adult Falls Program: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the CDC/NCIPC Child Injury Prevention Program (Core II)? CDC/NCIPC Child Injury Prevention Program (Core II) * YES, I received funding from the CDC/NCIPC Child Injury Prevention Program (Core II). NO, I did NOT receive funding from the CDC/NCIPC Child Injury Prevention Program (Core II).

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the CDC/NCIPC Child Injury Prevention Program. 2 of 6 --CDC/NCIPC Child Injury Prevention Program Confirmation * CDC/NCIPC Child Injury Prevention Program

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q85]? 2. Approximately what percentage of funding from the [Q85] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q85] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q85] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CDC/NCIPC Child Injury Prevention Program: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q85]? 4 of 6 --CDC/NCIPC Child Injury Prevention Program: Number of Staff Funde... *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the CDC/NCIPC Teen Dating Violence Initiative (Core II)? CDC/NCIPC Teen Dating Violence Initiative (Core II) * YES, I received funding from the CDC/NCIPC Teen Dating Violence Initiative (Core II). NO, I did NOT receive funding from the CDC/NCIPC Teen Dating Violence Initiative (Core II).

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the CDC/NCIPC Teen Dating Violence Initiative. 2 of 6 --CDC/NCIPC Teen Dating Violence Initiative Confirmation * CDC/NCIPC Teen Dating Violence Initiative

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q94]? 2. Approximately what percentage of funding from the [Q94] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q94] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q94] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CDC/NCIPC Teen Dating Violence Initiative: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q94]? 4 of 6 --CDC/NCIPC Teen Dating Violence Initiative: Number of Staff Funde... *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the CDC/NCIPC Core VIPP Base Integration Component (BIC)? CDC/NCIPC Core VIPP Base Integration Component (BIC) * YES, I received funding from the CDC/NCIPC Core VIPP Base Integration Component (BIC). NO, I did NOT receive funding from the CDC/NCIPC Core VIPP Base Integration Component (BIC).

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the CDC/NCIPC Core VIPP Base Integration Component (BIC). 2 of 6 --CDC/NCIPC Core VIPP Base Integration Component Confirmation * CDC/NCIPC Core VIPP Base Integration Component

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q103]? 2. Approximately what percentage of funding from the [Q103] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q103] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q103] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CDC/NCIPC Core VIPP Base Integration Component: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q103]? 4 of 6 --CDC/NCIPC Core VIPP Base Integration Component: Number of Staff ... *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding to be a CDC/NCIPC Core VIPP Regional Network Leader (RNL)? CDC/NCIPC Core VIPP Regional Network Leader (RNL) * YES, I received funding to be a CDC/NCIPC Core VIPP Regional Network Leader (RNL). NO, I did NOT receive funding to be a CDC/NCIPC Core VIPP Regional Network Leader (RNL).

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the CDC/NCIPC Core VIPP Regional Network Leader (RNL) Program. 2 of 6 --CDC/NCIPC Core VIPP Regional Network Leader Program Confirmation * Core VIPP Regional Network Leader Program

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q112]? 2. Approximately what percentage of funding from the [Q112] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q112] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q112] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CDC/NCIPC Core VIPP Regional Network Leader Program: Funding Amo... * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q112]? 4 of 6 --CDC/NCIPC Core VIPP Regional Network Leader Program: Number of S... *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the CDC/NCIPC Core VIPP Surveillance Quality Improvement (SQI) Program? CDC/NCIPC Core VIPP Surveillance Quality Improvement (SQI) Program * YES, I received funding from the CDC/NCIPC Core VIPP Surveillance Quality Improvement (SQI) Program. NO, I did NOT receive funding from the CDC/NCIPC Core VIPP Surveillance Quality Improvement (SQI) Program.

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the CDC/NCIPC Core VIPP Surveillance Quality Improvement (SQI) Program. 2 of 6 --CDC/NCIPC Core VIPP SQI Program Confirmation * Core VIPP Surveillance Quality Improvement Program

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q121]? 2. Approximately what percentage of funding from the [Q121] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q121] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q121] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CDC/NCIPC Core VIPP SQI Program: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q121]? 4 of 6 --CDC/NCIPC Core VIPP SQI Program: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the CDC/NCIPC Core VIPP Motor Vehicle Injury Prevention (MVP) Program? CDC/NCIPC Core VIPP Motor Vehicle Injury Prevention Program * YES, I received funding from the CDC/NCIPC Core VIPP Motor Vehicle Injury Prevention (MVP) Program. NO, I did NOT receive funding from the CDC/NCIPC Core VIPP Motor Vehicle Injury Prevention (MVP) Program.

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the CDC/NCIPC Core VIPP Motor Vehicle Injury Prevention Program. 2 of 6 --CDC/NCIPC Core VIPP Motor Vehicle Injury Prevention Program Confi... * Core VIPP Motor Vehicle Injury Prevention Program

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q130]? 2. Approximately what percentage of funding from the [Q130] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q130] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q130] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CDC/NCIPC Core VIPP Motor Vehicle Injury Prevention Program: Fun... * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q130]? 4 of 6 --CDC/NCIPC Core VIPP Motor Vehicle Injury Prevention Program: Num... *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the CDC/NCIPC Core VIPP Falls Among Older Adults Program? CDC/NCIPC Core VIPP Falls Among Older Adults Program * YES, I received funding from the CDC/NCIPC Core VIPP Falls Among Older Adults Program. NO, I did NOT receive funding from the CDC/NCIPC Core VIPP Falls Among Older Adults Program.

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the CDC/NCIPC Core VIPP Falls Among Older Adults Program. 2 of 6 --CDC/NCIPC Core VIPP Falls Among Older Adults Confirmation * Core VIPP Falls Among Older Adults Program

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q139]? 2. Approximately what percentage of funding from the [Q139] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q139] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q139] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CDC/NCIPC Core VIPP Falls Among Older Adults: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q139]? 4 of 6 --CDC/NCIPC Core VIPP Falls Among Older Adults: Number of Staff Fu... *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the CDC/NCIPC National Violent Death Reporting System (NVDRS)? CDC/NCIPC National Violent Death Reporting System (NVDRS) * YES, I received funding from the CDC/NCIPC National Violent Death Reporting System (NVDRS). NO, I did NOT receive funding from the CDC/NCIPC National Violent Death Reporting System (NVDRS).

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the CDC/NCIPC National Violent Death Reporting System (NVDRS). 2 of 6 --CDC/NCIPC NVDRS Confirmation * National Violent Death Reporting System (NVDRS)

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q148]? 2. Approximately what percentage of funding from the [Q148] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q148] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q148] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CDC/NCIPC NVDRS: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q148]? 4 of 6 --CDC/NCIPC NVDRS: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the CDC/NCIPC Rape Prevention and Education (RPE) Program? CDC/NCIPC Rape Prevention and Education (RPE) Program * YES, I received funding from the CDC/NCIPC Rape Prevention and Education (RPE) Program. NO, I did NOT receive funding from the CDC/NCIPC Rape Prevention and Education (RPE) Program.

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the CDC/NCIPC Rape Prevention and Education (RPE) Program. 2 of 6 --CDC/NCIPC RPE Confirmation * Rape Prevention and Education (RPE) Program

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q157]? 2. Approximately what percentage of funding from the [Q157] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q157] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q157] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CDC/NCIPC RPE: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q157]? 4 of 6 --CDC/NCIPC RPE: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the CDC/NCIPC Domestic Violence Prevention Enhancement and Leadership Through Alliances (DELTA) Program? CDC/NCIPC Domestic Violence Prevention Enhancement and Leadership Through A... * YES, I received funding from the CDC/NCIPC Domestic Violence Prevention Enhancement and Leadership Through Alliances (DELTA) Program. NO, I did NOT receive funding from CDC/NCIPC Domestic Violence Prevention Enhancement and Leadership Through Alliances (DELTA) Program.

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the CDC/NCIPC Domestic Violence Prevention Enhancement and Leadership Through Alliances (DELTA) Program. 2 of 6 --CDC/NCIPC DELTA Confirmation * DELTA Program

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q166]? 2. Approximately what percentage of funding from the [Q166] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q166] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q166] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CDC/NCIPC DELTA: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q166]? 4 of 6 --CDC/NCIPC DELTA: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the CDC/NCIPC Residential Fire-related Injury Prevention Program? CDC/NCIPC Residential Fire-related Injury Prevention Program * YES, I received funding from the CDC/NCIPC Residential Fire-related Injury Prevention Program. NO, I did NOT receive funding from the CDC/NCIPC Residential Fire-related Injury Prevention Program.

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the CDC/NCIPC Residential Fire-related Injury Prevention Program. 2 of 6 --CDC/NCIPC Residential Fire-related Injury Prevention Confirmation * Residential Fire-related Injury Prevention Program

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q175]? 2. Approximately what percentage of funding from the [Q175] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q175] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q175] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CDC/NCIPC Residential Fire-related Injury Prevention: Funding Am... * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q175]? 4 of 6 --CDC/NCIPC Residential Fire-related Injury Prevention: Number of ... *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the CDC Preventive Health and Health Services (PHHS) Block Grant? CDC Preventive Health and Health Services (PHHS) Block Grant * YES, I received funding from the CDC Preventive Health and Health Services (PHHS) Block Grant. NO, I did NOT receive funding from the CDC Preventive Health and Health Services (PHHS) Block Grant.

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the CDC Preventive Health and Health Services (PHHS) Block Grant. 2 of 6 --CDC PHHS Block Grant Confirmation * Preventive Health and Health Services (PHHS) Block Grant

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q184]? 2. Approximately what percentage of funding from the [Q184] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q184] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q184] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CDC PHHS Block Grant: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q184]? 4 of 6 --CDC PHHS Block Grant: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the CDC Communities Putting Prevention to Work (CPPW) Program? CDC Communities Putting Prevention to Work (CPPW) Program * YES, I received funding from the CDC Communities Putting Prevention to Work (CPPW) Program. NO, I did NOT receive funding from the CDC Communities Putting Prevention to Work (CPPW) Program.

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the CDC Communities Putting Prevention to Work (CPPW) Program. 2 of 6 --CDC CPPW Confirmation * Communities Putting Prevention to Work (CPPW) Program

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q193]? 2. Approximately what percentage of funding from the [Q193] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q193] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q193] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CDC CPPW: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q193]? 4 of 6 --CDC CPPW: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the Consumer Product Safety Commission (CPSC)? Consumer Product Safety Commission * YES, I received funding from the Consumer Product Safety Commission (CPSC). NO, I did NOT receive funding from the Consumer Product Safety Commission (CPSC).

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the Consumer Product Safety Commission (CPSC). 2 of 6 --CPSC Confirmation * Consumer Product Safety Commission (CPSC)

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q202]? 2. Approximately what percentage of funding from the [Q202] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q202] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q202] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --CPSC: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q202]? 4 of 6 --CPSC: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the Federal Emergency Management Agency (FEMA)? Federal Emergency Management Agency (FEMA) * YES, I received funding from the Federal Emergency Management Agency (FEMA). NO, I did NOT receive funding from the Federal Emergency Management Agency (FEMA).

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the Federal Emergency Management Agency (FEMA). 2 of 6 --FEMA Confirmation * Federal Emergency Management Agency (FEMA)

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q211]? 2. Approximately what percentage of funding from the [Q211] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q211] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q211] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --FEMA: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q211]? 4 of 6 --FEMA: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the HRSA/MCHB Title V Block Grant? HRSA/MCHB Title V Block Grant * YES, I received funding from the HRSA/MCHB Title V Block Grant. NO, I did NOT receive funding from the HRSA/MCHB Title V Block Grant.

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the HRSA/MCHB Title V Block Grant. 2 of 6 --HRSA/MCHB Title V Block Grant Confirmation * HRSA/MCHB Title V Block Grant

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q220]? 2. Approximately what percentage of funding from the [Q220] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q220] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q220] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --HRSA/MCHB Title V Block Grant: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q220]? 4 of 6 --HRSA/MCHB Title V Block Grant: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the HRSA/MCHB Emergency Medical Services for Children Program. 2 of 6 --HRSA/MCHB EMSC Program Confirmation * HRSA/MCHB EMSC Program

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q229]? 2. Approximately what percentage of funding from the [Q229] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q229] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q229] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --HRSA/MCHB EMSC Program: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q229]? 4 of 6 --HRSA/MCHB EMSC Program: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the NHTSA CODES Program. 2 of 6 --NHTSA CODES Program Confirmation * NHTSA CODES Program

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q238]? 2. Approximately what percentage of funding from the [Q238] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q238] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q238] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --NHTSA CODES Program: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q238]? 4 of 6 --NHTSA CODES Program: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the National Highway Traffic Safety Administration (NHTSA) for any other programs? NOTE: Only include any other funding received directly from NHTSA. Do not include funding from CODES or from your state DOT or State Highway Safety Office. National Highway Traffic Safety Administration (NHTSA) -Other * YES, I received funding from NHTSA for other programs. NO, I did NOT receive funding from NHTSA for other programs.

2011 SOTS Finance & Personnel Survey

1. Please provide the name(s) of the other NHTSA program(s) for which you have received funding. 2 of 6 --Other NHTSA Programs: Names *

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q247]? 2. Approximately what percentage of funding from the [Q247] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q247] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q247] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --Other NHTSA Programs: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q247]? 4 of 6 --Other NHTSA Programs: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from SAMHSA Campus Suicide Prevention Grants? SAMHSA Campus Suicide Prevention Grants * YES, I received funding from SAMHSA Campus Suicide Prevention Grants. NO, I did NOT receive funding from SAMHSA Campus Suicide Prevention Grants.

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from SAMHSA Campus Suicide Prevention Grants. 2 of 6 --SAMHSA Campus Suicide Prevention Grants Confirmation * SAMHSA Campus Suicide Prevention Grants

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q256]? 2. Approximately what percentage of funding from the [Q256] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q256] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q256] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --SAMHSA Campus Suicide Prevention Grants: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q256]? 4 of 6 --SAMHSA Campus Suicide Prevention Grants: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from SAMHSA State and Tribal Youth Suicide Prevention Grants? SAMHSA State and Tribal Youth Suicide Prevention Grants * YES, I received funding from SAMHSA State and Tribal Youth Suicide Prevention Grants. NO, I did NOT receive funding from SAMHSA State and Tribal Youth Suicide Prevention Grants.

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from SAMHSA State and Tribal Youth Suicide Prevention Grants. 2 of 6 --SAMHSA State and Tribal Youth Suicide Prevention Grants Confirmat... * SAMHSA State and Tribal Youth Suicide Prevention Grants

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q265]? 2. Approximately what percentage of funding from the [Q265] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q265] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q265] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --SAMHSA State and Tribal Youth Suicide Prevention Grants: Funding... * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q265]? 4 of 6 --SAMHSA State and Tribal Youth Suicide Prevention Grants: Number ... *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the U.S. Department of Justice? U.S. Department of Justice * YES, I received funding from the U.S. Department of Justice. NO, I did NOT receive funding from the U.S. Department of Justice.

2011 SOTS Finance & Personnel Survey

1. If you answered "YES" in the previous question, please click the circle below confirming that you received funding from the U.S. Department of Justice. 2 of 6 --U.S. Department of Justice Confirmation * U.S. Department of Justice

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q274]? 2. Approximately what percentage of funding from the [Q274] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q274] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q274] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --U.S. Department of Justice: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q274]? 4 of 6 --U.S. Department of Justice: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from the U.S. Department of Transportation? NOTE: Do not include funding from NHTSA, from your state DOT, or State Highway Safety Office. U.S. Department of Transportation * YES, I received funding from the U.S. Department of Transportation. NO, I did NOT receive funding from the U.S. Department of Transportation.

2011 SOTS Finance & Personnel Survey

1. Please provide the name(s) of the U.S. Department of Transportation program(s) for which you have received funding. 2 of 6 --U.S. Department of Transportation Confirmation *

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q283]? 2. Approximately what percentage of funding from the [Q283] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q283] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q283] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --U.S. Department of Transportation: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q283]? 4 of 6 --U.S. Department of Transportation: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from any corporations? Corporations * YES, I received funding from corporations. NO, I did NOT receive funding from corporations.

2011 SOTS Finance & Personnel Survey

1. Please provide the name(s) of the corporation(s) from which you have received funding. NOTE: Please use commas to separate each name. 2 of 6 --Corporations: Names *

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q292]? 2. Approximately what percentage of funding from the [Q292] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q292] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q292] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --Corporations: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q292]? 4 of 6 --Corporations: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from any foundations? Foundations * YES, I received funding from foundations. NO, I did NOT receive funding from foundations.

2011 SOTS Finance & Personnel Survey

1. Please provide the name(s) of the foundation(s) from which you have received funding. NOTE: Please use commas to separate each name. 2 of 6 --Foundations: Names *

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q301]? 2. Approximately what percentage of funding from the [Q301] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q301] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q301] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --Foundations: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q301]? 4 of 6 --Foundations: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from any non-profit organizations (e.g., Safe Kids, Public Health Institutes, etc.)? Non-Profit Organizations * YES, I received funding from non-profit organizations. NO, I did NOT receive funding from non-profit organizations.

2011 SOTS Finance & Personnel Survey

1. Please provide the name(s) of the non-profit organization(s) from which you have received funding. NOTE: Please use commas to separate each name. 2 of 6 --Non-Profit Organizations: Names *

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q310]? 2. Approximately what percentage of funding from the [Q310] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q310] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q310] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --Non-Profit Organizations: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q310]? 4 of 6 --Non-Profit Organizations: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from a university or academic institution? Universities and Academic Institutions * YES, I received funding from a university or academic institution. NO, I did NOT receive funding from a university or academic institution.

2011 SOTS Finance & Personnel Survey

1. Please provide the name(s) of the academic institution(s) from which you have received funding. NOTE: Please use commas to separate each name. 2 of 6 --University & Academic Institutions: Names *

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q319]? 2. Approximately what percentage of funding from the [Q319] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q319] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q319] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --University & Academic Institutions: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q319]? 4 of 6 --University & Academic Institutions: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2011 (October 1, 2010 -September 30, 2011), did you receive funding from any additional funding source(s) that have not been listed previously? Other Funding Sources * YES, I received funding from additional funding source(s) that were not listed previously. NO, I did NOT receive funding from any additional funding sources.

2011 SOTS Finance & Personnel Survey

1. Please provide the name(s) of the additional funding source(s) from which you have received funding. NOTE: Please use commas to separate each name. 2 of 6 --Other Funding Sources: Names *

2011 SOTS Finance & Personnel Survey

1. Between October 1, 2010 -September 30, 2011, what is the total amount of funding you will receive from the [Q328]? 2. Approximately what percentage of funding from the [Q328] is used for the following categories? PLEASE NOTE: The sum total of all five categories should equal 100%. 3. Did you receive funding from the [Q328] in Federal Fiscal Year 2010 (October 1, 2009 ­September 30, 2010)? 4. Do you anticipate receiving funding from the [Q328] in Federal Fiscal Year 2012 (October 1, 2011 -September 30, 2012)? 3 of 6 --Other Funding Sources: Funding Amounts * * Personnel (Salary & Fringe) Safety Equipment Grants/Mini-Grants/Contracts Overhead Expenses (Indirect Costs) Other (e.g., travel, meetings, educational materials, surveillance systems, etc.) * * YES, the same level of funding from this source as Federal Fiscal Year 2011. YES, but LESS funding from this source in Federal Fiscal Year 2011. YES, but MORE funding from this source in Federal Fiscal Year 2011. NO, I did not receive funding from this source in Federal Fiscal Year 2010. I don't know if I received funding from this source in Federal Fiscal Year 2010. YES, it is confirmed and funding will be at the same level. YES, it is confirmed and funding will be MORE than Federal Fiscal Year 2011. YES, it is confirmed and funding will be LESS than Federal Fiscal Year 2011. It is likely, but not confirmed. It is unknown if funding will be available. NO, no funding from this source is anticipated for Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

1. You have indicated that you have a total staff of [Q3]. During Federal Fiscal Year 2011, how many of these staff positions were funded by the [Q328]? 4 of 6 --Other Funding Sources: Number of Staff Funded *

2011 SOTS Finance & Personnel Survey

1. What has been the impact of budget cuts that you experienced since October 1, 2010? (Choose all the apply.) Budget/Economic Issues * Staff layoffs Staff furloughs Loss of staff through attrition Elimination of entire program(s) Reduction in surveillance efforts Reduction in services Reduction in support to partners Reduction in support to local health departments Other (please specify)

2011 SOTS Finance & Personnel Survey

1. In Federal Fiscal Year 2012, which of the following scenarios do you expect to experience? Federal Fiscal Year 2012 I expect more budget cuts. I expect level funding. I expect budget increases. I'm not sure what to expect with regard to funding in Federal Fiscal Year 2012.

2011 SOTS Finance & Personnel Survey

You have completed the 2011 State of the States Finance & Personnel Survey. Thank you for your time and participation. Please contact Jamila Porter at 770-690-9000 or jamila.porter@safestates.org if you have any questions about the survey. Thank You