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Local Respondent Information Form (RIF) Local Public Health System Performance Assessment Instrument 71 Local Respondent Information Form (RIF) Demographic Information Name of Local Health Department: Address State Zip Email Phone Fax Agency website URL Name of Local Health Officer Name of Contact Person for the Assessment Instrument Contact Person Title Contact Person Phone Fax Email 1. Categorize your jurisdiction by selecting one of the following, or describe its structure under “other.” a. County b. City c. City-County d. Township e. Multiple counties, district, or regional health department f. Other 2. What is the population of your jurisdiction: a. Population: b. Year of population estimate 3. How many people are employed by your local health department? Total FTEs: 4. What is the total agency budget? 5.  hich of the following best describes the organization or office to which your local public health officer reports directly? W (check all that apply) a. Local board of health b. City council / county council c. County commissioner / county executive d. City or town manager e. Regional or district health director f. State health director or commissioner g. Other 6. How much time has the local health official held his/her position? years months 7. s your jurisdiction completing the local public health system assessment as part of the MAPP (Mobilizing for Action through Planning I and Partnerships) process? a. Yes b. No c. Unsure (Note: MAPP is a community strategic planning process that incorporates the results of the local public health system assessment into a broader plan for improving community health. For more information about MAPP, go to www.naccho.org and click on “Programs and Activities” and then the link for MAPP.) 72 Local Public Health System Performance Assessment Instrument Local About Your Site’s Assessment Process Please tell us about your jurisdiction’s experience with the NPHPSP assessment. The assessment coordinator should answer evaluation questions on behalf of the site, based on observations of the process and input from participants. 8.  uring the assessment process, what type of decision making process was used? D (Check the response that best describes your process.) Walked through the instrument and voted on questions one-by-one. Discussed the model standards with follow-up voting on each question. Reviewed, discussed, and voted on sub-questions before voting on stem (first tier questions). Discussed the model standards with facilitator/recorder judgment on responses. Other (Please describe): 9.  hat process was used to complete the 10 sections of the assessment? W (Check only one response.)  One large meeting during which the group was broken into separate small groups to address 2-3 Essential Services per group. One large meeting during which the same group responded to the entire assessment instrument together.  series of meetings during which one or two Essential Services were addressed at each meeting by the same group A throughout the entire process.  series of meetings during which one or two Essential Services were addressed at each meeting by a core group which A invited specific expertise to the meetings, based on the Essential Service that was completed. Other (Please describe): 10. Participation - please indicate the number and type of public health system representatives involved in the assessment process. a. Total number of participants: b. From the list below, select the types of organizations that participants represented. (Check all that apply.) The local governmental public health agency The local governing entity (e.g., board of health) Other governmental entities (e.g., state agencies, other local agencies) Hospitals Managed care organizations Primary care clinics and physicians Social service providers Local businesses and employers Neighborhood organizations Faith institutions Transportation providers Educational institutions Public safety and emergency response organizations Environmental and occupational health organizations Advocacy groups Community residents Other: Other: Other: Other: Local Public Health System Performance Assessment Instrument 73 Local 11. To date, what effect has the assessment process had on the following among public health systems partners? Negative Effect Somewhat Negative Effect No Effect Somewhat Positive Effect Positive Effect Communications Collaboration K  nowledge of the public health system K  nowledge of system improvement needs I ntent to implement system improvements 12. How satisfied were you with the following aspects of the National Program? Dissatisfied Somewhat dissatisfied Neutral Somewhat satisfied Satisfied N/A User Guide On-line Toolkit Trainings T  oll-Free Helpline (800#) Email Help box 13. How satisfied were you with the overall experience of the NPHPSP assessment process? (circle one) Dissatisfied 1 74 Somewhat dissatisfied 2 Neutral 3 Somewhat satisfied 4 Satisfied 5 Local Public Health System Performance Assessment Instrument N/A 6 Local 14. Would you complete the NPHPSP assessment process again? Yes No Maybe 15. Please provide any additional comments on your experience with the NPHPSP process: Next Steps: Performance Improvement 16.  s a result of completing the assessment, which of the following performance improvement steps do you expect to implement A in the next six months to address particular Essential Services or Model Standards? Convene participants for performance improvement Prioritize areas for action Analyze “root causes” of performance Develop action plans Implement action plans Monitor progress Report progress None Local Public Health System Performance Assessment Instrument 75