0920-1009 Attachment B_Instrument

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Attachment B_Instrument

Assessing the Effectiveness of HEADS UP Message

OMB: 0920-1009

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ATTACHMENT B: INSTRUMENT


Form Approved
OMB No: 0920-1009
Exp. Date: 3/31/2017

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Public Reporting burden of this collection of information is estimated at 15 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-74, Atlanta, GA 30333; Attn: PRA (0920-1009).









Thank you for agreeing to participate in this survey about your organization’s experience with the CDC HEADS UP resources. This survey asks questions about your organization’s awareness of the CDC HEADS UP resources, and your experience using and sharing the HEADS UP resources within your organization and with other organizations. The findings from this survey will help CDC better understand how the HEADS UP materials are used and shared, and how they can improve future dissemination. Below are a few notes about the survey:

  • Your input is important. Your participation in this survey is voluntary. You may choose not to participate. You may also choose to stop the survey at any time, or not answer a question, for any reason. The survey will take approximately 20 minutes. It is being administered by ICF International, in partnership with CDC.

  • Benefits: Your participation will not result in any direct benefits to you. Your input will help to provide a better understanding of how CDC HEADS UP materials are used and shared.

  • Risks: There are no potential risks to you or your organization associated with participating in this survey.

  • Confidentiality: Your identity will not be disclosed and the survey will only be connected to your organization anonymously as having been completed by a representative.

  • Contact information: If you have any concerns about completing this survey or have any questions about the study, please Rosanne Hoffman, Rosanne.hoffman@icfi.com, 301-407-6596.


Organization Demographics

  1. Organization Name:

  2. What is your role/title?

    • Organizational leadership (e.g. Executive Director, President, CEO, other Chief Officer)

    • Program director

    • Program staff

    • Administrative staff (e.g. finance, development, human resources)

    • Researcher

    • Health Care Provider

    • School Professional

    • Coach

    • Volunteer

    • Other (specify)

  3. How often do you focus on concussion in your work?

    • Very often

    • Somewhat often

    • Not very often

    • Not often at all

CDC HEADS UP Material Use at Organizational Level

  1. How long have you been using CDC HEADS UP materials?

    • >1 year

    • 1-3 years

    • 4-7 years

    • 7-11 years

    • 11-12 years

  2. What CDC HEADS UP materials do you find most useful? (Check all that apply)

  3. From where do you receive information about CDC HEADS UP? (Check all that apply)

    • CDC HEADS UP Website

    • Emails from CDC

    • CDC HEADS UP Facebook page

    • National sports organization (list specific name of org)

    • Local sports organization (list name of org)

    • National education organization (list name of org)

    • School or local education association (list name of org)

    • Professional medical association (list name of org)

    • Health care system/ health care professional (list name of health care system)

    • A colleague

    • Other (please specify):

  4. How often do you receive information about CDC HEADS UP?

  • 7 or more times a year

    • 3-6 times a year

    • 1-2 times a year

    • Never

  1. How do you use CDC HEADS UP materials within your organization? (Select all that apply)

  • As part of general health promotion education

  • As part of a concussion prevention program

  • To educate colleagues within my organization about concussion

  • To help our regional and local affiliates develop concussion prevention programs

  • To support our programs that educate health care providers about concussion

  • To support our programs that educate coaches about concussion

  • To support our programs that educate school professionals about concussion

  • To support our programs that educate athletes about concussion

  • To support our programs that educate parents about concussion

  • Other (please specify):

  1. How often to do you share CDC HEADS UP materials and resources with colleagues within your organization?

  • 7 or more times a year

    • 3-6 times a year

    • 1-2 times a year

    • Never

  1. Who do you disseminate CDC HEADS UP materials to within your organization?

  • Education/Training Director

  • Communication/Marketing Director

  • Program/Organization Director

  • Membership Director/Liaison

  • Human Resources Specialist

  • Health Education Specialist

  • Health care provider

  • Other health professional

  • School professional

  • Coaching or sports professional

  • Other (please specify):

  1. How do your colleagues use the CDC HEADS UP materials after you share them? (Select all that apply)

  • Download and print the materials to use as reference

  • Forward them to other colleagues or programs

  • Conduct a training at a conference or meeting

  • Download and print materials to give to coaches

  • Download and print materials to give to parents

  • Download and print materials to give to athletes

  • Download and print materials to give to school professionals

  • Download and print materials to give to health care providers

  • Other (please specify):

  1. How familiar are you with the CDC HEADS UP information on how to spot a concussion?

    • Very Familiar

    • Somewhat Familiar

    • Not Very Familiar

    • Not Familiar At All

  2. How familiar are you with the CDC HEADS UP information on return to learn?

    • Very Familiar

    • Somewhat Familiar

    • Not Very Familiar

    • Not Familiar At All

  3. How familiar are you with the CDC HEADS UP information on return to play?

    • Very Familiar

    • Somewhat Familiar

    • Not Very Familiar

    • Not Familiar At All

  4. How familiar are you with the CDC HEADS UP Action Plan?

    • Very Familiar

    • Somewhat Familiar

    • Not Very Familiar

    • Not Familiar At All

  5. Do you use any CDC HEADS UP concussion information in your website content, protocols, or organization’s communication with your key audience?

    • Yes

    • No

    • Don’t know


Other Concussion Information

  1. Do you receive any other concussion information besides information about HEADS UP?

  • Yes

  • No

  • Don’t know

  1. From where do you receive other concussion information?

    • National sports organization (list specific name of org)

    • Local sports organization (list name of org)

    • National education organization (list name of org)

    • School or local education association (list name of org)

    • Professional medical association (list name of org)

    • Health care system/ health care professional (list name of health care system)

    • A colleague

    • Other (please specify):

  2. How often do you receive other information or educational materials about concussion?

  • 7 or more times a year

    • 3-6 times a year

    • 1-2 times a year

    • Never

  1. How do you use other concussion materials within your organization? (Include a range of options)

  • Download and print the materials to use as reference

  • Forward them to other colleagues or programs

  • Conduct a training at a conference or meeting

  • Download and print materials to give to coaches

  • Download and print materials to give to parents

  • Download and print materials to give to athletes

  • Download and print materials to give to school professionals

  • Download and print materials to give to health care providers

  • Other (please specify):

Inter-Organization Use and Interactions

  1. What types of organizations do you share CDC HEADS UP materials with (check all that apply)?

  • National or regional health organization(s)

  • National or regional sports organization(s)

  • National or regional schools or education-related organization(s)

  • National or regional parenting organization(s)

  • National youth-serving organization(s)

  • Local health organization(s)

  • Local sports organization(s)

  • Local schools or education-related organization(s)

  • Local parenting organization(s)

  • Local youth-serving organizations(s)

  • Local community center

  • Other (please specify):


  1. How often do you share CDC HEADS UP materials and resources with this organization?

    • Weekly

    • Monthly

    • Quarterly

    • Yearly


  1. How do you share this information?


  1. Which CDC HEADS UP materials do you share with outside organizations?


  1. Why do you share these materials?



  1. Do you share CDC HEADS UP materials directly with any of the following community groups or members?

  • Coaches

  • Student-Athletes

  • Parents

  • Health Care Professionals

  • School Professionals

  • Sports Officials

Perception of CDC HEADS UP Materials

  1. Are the HEADS UP materials clear and easy to understand?

  • YES

  • NO

  1. Have you thought about the contents of the material since you read it?

  • NEVER

  • RARELY

  • SOMETIMES

  • OFTEN

  1. How would you rate the CDC HEADS UP materials?

  1. Not useful

  2. Somewhat useful

  3. Useful

  4. Very useful

  5. Extremely useful

  1. Have you used or cited the HEADS UP materials in your own materials or education efforts?

  • YES

  • NO

  • DON’T KNOW

  1. Do you plan to use or cite use HEADS UP in your own materials?

  • YES

  • NO

  • DON’T KNOW

  1. What do you like best about the CDC HEADS UP materials that you use?

  2. What would make CDC HEADS UP materials better?


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