3 CERV-Net Pre-Test

Introduction

Hello! We’re excited to have you join us for the CERV-Net Learning Series. Please
complete the following survey by March 7, 2024 to help the CERV-Net team prepare for this
training.

Public Burden Statement:
On behalf of HRSA OWH, NORC is evaluating the CERV-Net Learning Series to determine the impact
of the learning series on providers’ knowledge, skills, and intention to change their behavior related to
cervical cancer care. This Pre-Test is one form of data collection being used for this evaluation. 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. The OMB control number for this
information collection is 0906-0084 and it is valid until 02/27/2027. This information collection is
voluntary. Participant information provided as a part of this evaluation will be kept confidential on
NORC’s secure servers and will only be accessible by project team members. Participant name, role,
organization, and contact information will be provided to HRSA, the Federal Cervical Cancer
Collaborative, and others in the learning series to improve collaboration even after the learning series
ends. Public reporting burden for this collection of information is estimated to average 15 minutes per
response, including the time for reviewing instructions, searching existing data sources, and completing
and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to HRSA
Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857
or paperwork@hrsa.gov.

Demographics

What is your first name?

What is your last name?

How did you learn about CERV-Net?
Direct outreach from HRSA Project Officer
Direct outreach from NORC
HRSA Newsletter
From a colleague
Other, please specify:

Have you ever participated in any ECHO sessions before?
Yes
No
Don't know

Which of the following best describes your gender identity?

Female
Male
Transgender
Nonbinary/Genderqueer
Don't know
Prefer not to answer

Which of the following best describes your race and ethnicity? Select all that apply. 
White
Black or African American
Hispanic or Latino
Asian
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Other, please specify:

Pre-Test

Rate your knowledge of (or skill in) the following topics before the course: 

Recall HPV
vaccination guidelines
and understand when   
deviations are
appropriate
Feel confident making
a strong

recommendation
Apply strategies for
discussing
vaccination and
addressing common
concerns with
patients and parents

Understand how to
adapt Community
Guide recommended
vaccination
interventions in a
safety-net setting

Discuss real-world
facilitators and
barriers to
intervention
implementation for
different settings

Identify opportunities
for forming
partnerships to
improve vaccination
rates

Not at all
knowledgeable
or skilled

Slightly
knowledgeable
or skilled

Moderately
knowledgeable
or skilled

Very
knowledgeable
or skilled

Rate your knowledge of (or skill in) the following topics before the course: 

Describe the
spectrum of diverse
patient needs and the

importance of
providing patientcentered exams
Incorporate best
practices for
describing and

delivering services for
special populations
into routine care
Use inclusive and
trauma-informed
language to describe
screening tests and
results

Recall and apply
routine screening
guidelines for Pap
and Primary HPV,
eligibility and exit
criteria

Feel confident
training other
providers about

screening guidelines
and eligibility and exit
criteria

Not at all
knowledgeable
or skilled

Slightly
knowledgeable
or skilled

Moderately
knowledgeable
or skilled

Very
knowledgeable
or skilled

Not at all
knowledgeable
or skilled

Slightly
knowledgeable
or skilled

Moderately
knowledgeable
or skilled

Very
knowledgeable
or skilled

Understand how to
adapt Community
Guide recommended
screening
interventions in a
safety-net setting

Rate your knowledge of (or skill in) the following topics before the course: 
Not at all
knowledgeable
or skilled
Discuss real-world
facilitators and
barriers to
implementing
interventions for
different settings
Apply 2019 ASCCP
management
guidelines and
understand changes
from previous
guidance
Recognize
appropriate
surveillance needs
after treatment of
CIN2 or CIN3

Slightly
knowledgeable
or skilled

Moderately
knowledgeable
or skilled

Very
knowledgeable
or skilled

Apply management
guidelines and
assess individual risk
using available tools
(ASCCP app)

Not at all
knowledgeable
or skilled

Slightly
knowledgeable
or skilled

Moderately
knowledgeable
or skilled

Very
knowledgeable
or skilled

Explain test types and

results to patients
Understand how to
adapt Community
Guide recommended
management
interventions in a
safety-net setting

Rate your knowledge of (or skill in) the following topics before the course: 

Discuss real-world
facilitators and
barriers to
implementing
interventions for
different settings

Use tools for
assessing capacity
and readiness for
change and quality
improvement

Not at all
knowledgeable
or skilled

Slightly
knowledgeable
or skilled

Moderately
knowledgeable
or skilled

Very
knowledgeable
or skilled

Not at all
knowledgeable
or skilled

Slightly
knowledgeable
or skilled

Moderately
knowledgeable
or skilled

Very
knowledgeable
or skilled

Identify organizational
QI needs and

implement QI
exercises
Identify change
management
strategies and
sustaining practice
change

Describe emerging
innovations (e.g., selfsampling) and

potential impact on
safety-net settings of
care

Please rate your level of agreement with the following statements:

I am confident in my
ability to provide
cervical cancer care.

I am committed to
improving cervical
cancer care in my
practice.

Strongly
disagree

Disagree

Neutral

Agree

Strongly
agree

Strongly
disagree

Disagree

Neutral

Agree

Strongly
agree

Agree

Strongly
agree

I have the information
I need to address

cervical cancer in my
practice.

Please rate your level of agreement with the following statements:

I believe that I can
contribute to systemlevel changes for
improving cervical
cancer care (e.g.,
implement
interventions, improve

data collection,
protocols, and
procedures,
implement training,
form partnerships,
increase community
engagement).
I am confident in my
ability to contribute to
system-level changes
for improving cervical
cancer care.

I am committed to
contributing to
system-level changes
for improving cervical
cancer care.

Strongly
disagree

Disagree

Neutral

Please rate your level of agreement with the following statements:
Strongly
disagree

Disagree

Neutral

Agree

Strongly
agree

I feel connected to
colleagues working in
other safety-net
settings.
I would reach out to
colleagues working in
other safety-net
settings with
questions about
improving cervical
cancer prevention,
screening, and
management.

Do you have any feedback on the marketing of this learning series (i.e., length of marketing
materials, clarity, etc.)?

OMB No. 0906-0084
ICR expiration date: 02/27/2027
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