RNL Needs Assessment Survey

Attachment I – Core VIPP Evaluation

Form Approved
OMB No. 0920-0916
Exp. Date:

Regional Injury Prevention Network - Needs Assessment

Public Reporting burden of this collection of information is estimated at 60 minutes per response, including the time 
for reviewing instructions, research exiting 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 D­74, Atlanta, GA 30333; Attn: 
PRA (0920­0916). 

Regional Network Needs Assessment
The purpose of this needs assessment survey is to provide your Regional Network with important information that will 
guide the development of in­person and online trainings, technical assistance, and resources that will be helpful to 
your state and region.  
Plus! There is free help for your work available based on this survey. We are able to match up experts with programs 
in our region interested in tackling a particular injury or violence prevention issue—let us know what you need help 
with!  
This survey should take you approximately 60 minutes to complete. 

Regional Network Needs Assessment

If you need assistance on how to respond to questions in this needs assessment, please contact your local Regional 
Network Leader for your state. 

Regional Injury Prevention Network 7 & 8
Lori Haskett 
Director, Injury Prevention Program 
Kansas Department of Health and Environment 

lhaskett@kdheks.gov 
785­296­8163 

Regional Network Members 
Colorado, Iowa, Kansas, Missouri, Montana, Nebraska, North Dakota, South Dakota, 
Utah, Wyoming 

General Information

Page 1

Regional Injury Prevention Network - Needs Assessment

*1. In which state is your Violence and Injury Prevention (VIP) Program located?
j Colorado
k
l
m
n
j Iowa
k
l
m
n

j North Dakota
k
l
m
n

j Nebraska
k
l
m
n

j Kansas
k
l
m
n

j Missouri
k
l
m
n

j South Dakota
k
l
m
n

j Montana
k
l
m
n

j Utah
k
l
m
n

j Wyoming
k
l
m
n

*2. Please provide the contact information for the person responsible for completing

this survey.
Name:
Title/Position:
Organization
Name:
Email
Address:

Needs Assessment Matrix

Instructions: Please indicate the level of expertise or programming the State Health Department (SHD) Violence and 
Injury Prevention (VIP) Program has in the following areas. To answer this question, each VIP will indicate its level of 
programming/experience/expertise on a scale, where 0 is Do Not Know, 1 is Low Levels, 2 is Moderate Levels, and 3 
represents High Levels of programming or expertise.  

Examples: 
0 – Do Not Know (Unknown if state VIP has any programming or expertise in this area.)  

1– Low Level (State has an unfunded or no mandate in this area. No VIP staff is assigned to the 
project and the VIP has not established any partners.)  

2– Moderate Level (State has a mandate for this area. One or more VIP staff is assigned to the 
project, but funding is inadequate for state­wide coverage and partners are not engaged.)  

3– High Level (State has an adequately­funded mandate for this area. One or more VIP staff is 
assigned and work with partners to reduce burden.)  

Page 2

Regional Injury Prevention Network - Needs Assessment

*PART 1 of 2
What is the Health Department VIP

Outside of the VIP program, what is 

program’s level of work in the 

the state health department’s level 

following areas?

of work in the following areas?

1. All Terrain Vehicle 

Outside of the state health
department, what is other state
agencies’ level of work in the 
following areas?

6

6

6

2. Child Abuse/neglect

6

6

6

3. Child Passenger Safety

6

6

6

4. Domestic/intimate 

6

6

6

5. Elder Abuse

6

6

6

6. Childhood Falls

6

6

6

7. Older Adult Falls

6

6

6

8. Fire and burn injury

6

6

6

9. Firearm injury

6

6

6

10. Homicide/Assault

6

6

6

11. Mass trauma /disaster­

6

6

6

6

6

6

6

6

6

6

6

6

(ATV) Injury

partner violence

related
12. Motor Vehicle 
occupant injury
13. Motorcycle/motorized 
scooter injury
14. Occupational Injury

Needs Assessment Matrix

Instructions: Please indicate the level of expertise or programming the State Health Department (SHD) Violence and 
Injury Prevention (VIP) Program has in the following areas. To answer this question, each VIP will indicate its level of 
programming/experience/expertise on a scale, where 0 is Do Not Know, 1 is Low Levels, 2 is Moderate Levels, and 3 
represents High Levels of programming or expertise.  

Examples: 
0 – Do Not Know (Unknown if state VIP has any programming or expertise in this area.)  

1– Low Level (State has an unfunded or no mandate in this area. No VIP staff is assigned to the 
project and the VIP has not established any partners.)  

2– Moderate Level (State has a mandate for this area. One or more VIP staff is assigned to the 
project, but funding is inadequate for state­wide coverage and partners are not engaged.)  

3– High Level (State has an adequately­funded mandate for this area. One or more VIP staff is 
assigned and work with partners to reduce burden.)  

Page 3

Regional Injury Prevention Network - Needs Assessment

*PART 2 of 2
What is the Health Department VIP

Outside of the VIP program, what is 

program’s level of work in the 

the state health department’s level 

following areas?

of work in the following areas?

Outside of the state health
department, what is other state
agencies’ level of work in the 
following areas?

15. Pedestrian injury

6

6

6

16. Bicycle injury

6

6

6

17. Bullying

6

6

6

18. Prescription drug 

6

6

6

6

6

6

6

6

6

21. School­based injury

6

6

6

22. Sexual assault/rape

6

6

6

23. Spinal cord injury

6

6

6

24. Drowning/ submersion 

6

6

6

6

6

6

26. Teen Dating Violence

6

6

6

27. Traumatic brain injury

6

6

6

28. Sports Concussions

6

6

6

overdose
19. Rural/agricultural 
injury
20. Suffocation and 
Sudden Unexplained 
Infant Death

injuries
25. Suicide/ suicide 
attempts

Additional Questions

Page 4

Regional Injury Prevention Network - Needs Assessment

*One purpose of our Regional Network is to support the work of states by sharing

tools, resources, and experiences with one another. Please indicate which topic areas
(if any) you would be willing to share your approaches, data collection tools, and/or
experiences with other states. (Select all that apply)
c None
d
e
f
g

c Fire and burn injury
d
e
f
g

c All Terrain Vehicle (ATV) Injury
d
e
f
g
c Bicycle injury
d
e
f
g
c Bullying
d
e
f
g

c Firearm injury
d
e
f
g

c Child Passenger Safety
d
e
f
g
c Childhood Falls
d
e
f
g

c Sexual assault/rape
d
e
f
g

c Motor Vehicle occupant injury
d
e
f
g

c Occupational Injury
d
e
f
g

Drowning/ submersion injuries

c Spinal cord injury
d
e
f
g

c Motorcycle/motorized scooter injury
d
e
f
g

c Domestic/intimate partner violence
d
e
f
g

c Elder Abuse
d
e
f
g

c School­based injury
d
e
f
g

c Mass trauma /disaster­related
d
e
f
g

c Child Abuse/neglect
d
e
f
g

c
d
e
f
g

c Rural/agricultural injury
d
e
f
g

c Homicide/Assault
d
e
f
g

c Older Adult Falls
d
e
f
g
c
d
e
f
g

Pedestrian injury

c Sports Concussions
d
e
f
g

c Suffocation and Sudden Unexplained 
d
e
f
g
Infant Death 

c Suicide/ suicide attempts
d
e
f
g

c Teen Dating Violence
d
e
f
g

c Prescription drug overdose
d
e
f
g

c Traumatic brain injury
d
e
f
g

Other (please specify) 

*Which topic areas do you think are the most important priorities for your Regional

Network to address? (Select all that apply)
c None
d
e
f
g

c Fire and burn injury
d
e
f
g

c All Terrain Vehicle (ATV) Injury
d
e
f
g
c Bicycle injury
d
e
f
g
c Bullying
d
e
f
g

c Firearm injury
d
e
f
g

c School­based injury
d
e
f
g

c Sexual assault/rape
d
e
f
g

c Mass trauma /disaster­related
d
e
f
g

c Child Abuse/neglect
d
e
f
g

c Child Passenger Safety
d
e
f
g
c Childhood Falls
d
e
f
g

c Motor Vehicle occupant injury
d
e
f
g

c Drowning/ submersion injuries
d
e
f
g

c Spinal cord injury
d
e
f
g

c Motorcycle/motorized scooter injury
d
e
f
g
c Occupational Injury
d
e
f
g

c Domestic/intimate partner violence
d
e
f
g

c Elder Abuse
d
e
f
g

c Rural/agricultural injury
d
e
f
g

c Homicide/Assault
d
e
f
g

c Older Adult Falls
d
e
f
g
c Pedestrian injury
d
e
f
g

c Sports Concussions
d
e
f
g

c Suffocation and Sudden Unexplained 
d
e
f
g
Infant Death 

c Suicide/ suicide attempts
d
e
f
g

c Teen Dating Violence
d
e
f
g

c Prescription drug overdose
d
e
f
g

c Traumatic brain injury
d
e
f
g

Other (please specify) 

Additional Questions

Page 5

Regional Injury Prevention Network - Needs Assessment
What would you like the Regional Network Leader to provide to your state?
5
6  

What expertise or assistance can you provide to the regional network? (Examples 
include technical assistance related to a specific program or expertise in field such as 
epidemiology, policy, or evaluation.)
5
6  

Please provide any additional comments or suggestions you may have.
5
6  

Regional Network Needs Assessment

Thank you for completing this needs assessment!

Your local Regional Network Leader looks forward to the assessment results  
and to assisting you in your Violence and Injury Prevention (VIP) programmatic initiatives.  

Regional Injury Prevention Network 7 & 8  
Lori Haskett 
Director, Injury Prevention Program 
Kansas Department of Health and Environment  

lhaskett@kdheks.gov 
785­296­8163 

Regional Network Members 
Colorado, Iowa, Kansas, Missouri, Montana, Nebraska, North Dakota, South Dakota, 
Utah, Wyoming 

Page 6