Cover Sheet for Example Documentation
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1 Cover Sheet for Example Documentation Please complete the following form and submit along with your documentation. If you have any questions, please us at The following documentation has been submitted to ASTHO for the Accreditation Library as a potential example of Health Department documentation that might meet the PHAB Domain 3 Standard 3.1 Measure 3.1.2A This document is not intended to be a template, but is a reference as state health agencies develop and select accreditation documentation specific to the health department's activities. Please note that the inclusion of documentation in this library does not indicate official approval or acceptance by PHAB. Document Title: Document Date: ADH OMHHD SU Campaign Pre & Post Survey Instrument & Results* Version of Standards and Measures Used: 1. Related PHAB Standard and Measure Number: 3.1.2A Domain: 3 Standard: 3.1 Measure: 3.1.2A Required Documentation: Short description of how this document meets the Standard and Measure s requirements: 2.1 This document contains examples of pre- and post-survey instruments and survey results to demonstrate that feedback was obtained from the target audience to develop the contents of the Sisters United (SU) Campaign. The objective of the SU Campaign was to increase infant mortality awareness among the African-American population by training sorority members to educate the African-American community about the infant mortality prevention. To develop this promotion strategy, input was solicited from African-American sorority members using pre-and post-survey instruments. Page 1: Pre-Survey instrument. Page 2: Post Survey Instrument. Pages 3-4: Survey results from sorority presidents meeting (6/212). Pages 5-6: Survey results from sorority trainers meeting (2/213). Page number references are noted on the lower left corner of the document. *Document received a score of Fully Demonstrated by PHAB during accreditation Submitting Arkansas Department of Health (ADH) Agency: Staff Contact Dr. Letitia de Graft-Johnson Name: Staff Contact Director, Office of Performance Improvement Management Position: Staff Contact Letitia.deGraft-Johnson@arkansas.gov Staff Contact (51) Phone: Can we attribute the document to your agency? ADH OMHHD SU Campaign Pre & Post survey instruments and results
2 Yes, you can include our agency name when posting No, please post the document anonymously Can we include staff name and contact information with the documentation? Yes, you can include staff contact information No, please do not include staff contact information Thank you for submitting your health agency s documentation to the Accreditation Library. We appreciate your contribution to this resource, and we look forward to continuing to provide you with assistance in your accreditation work. The following are PHAB s policies for all submitted documentation 1 : a. No draft documents will be accepted for review by PHAB. b. All documentation must be in effect and in use at the time that they are submitted to PHAB. c. Documents must be submitted to PHAB electronically. Hard copies of documents must be scanned into an electronic format for submission. PHAB will not accept hard copies of any documentation, either with documentation submission or at the site visit. In order for documentation to be considered by site visitors it must be in an electronic format and included in the health department s record of documentation in the e-phab system. d. A PDF version of all documentation is preferred. If a document is not a PDF, it should be in a commonly used program such as Word, Excel, or PowerPoint. Documents created using health department specific software, special graphics, or other program not commonly used, will not be accepted. e. In many cases, a measure is demonstrated only once, at a central point in the health department. Examples of these types of documentation requirements include department-wide policies (such as human resource policies), procedures, and plans. In these cases the requirement is for a specific, central document, rather than for examples. f. Where documentation requires examples, health departments must submit two examples, unless otherwise noted in the list of required documentation or the guidance. g. Health departments are encouraged to provide narrative that describes how the submitted document relates to and meets the requirement. Text boxes will be provided by e-phab for health departments to include descriptions and explanations. h. Health departments must comply with e-phab electronic submission requirements and processes. 1 PHAB requirements as listed in National Public Health Department Accreditation Documentation Guidance, page 2: Documentation-Guidance-Version-1..pdf ADH OMHHD SU Campaign Pre & Post survey instruments and results
3 ADH OMHHD SU Campaign Pre & Post survey instruments and results
4 ADH OMHHD Sisters United Campaign Pre-Survey (212/213) PRE-SURVEY Participant Information Form (PIF) Please check the box(es) next to the right answer(s): UNIQUE ID #: To create your unique ID number, use the month of your birth, the day of your birth, and the last four digits of your social security number. For example, for May 29 and the ID number would be Unique ID: M M D D # # # # TODAY'S DATE: ZIP CODE: AGE: SEX: M F Race White Black or African American Asian Native Hawaiian / Other Pacific Islander American Indian or Alaska Native Other [specify] Don t know / Not sure Ethnicity (Hispanic / Latino) Yes No Don t know / Not sure 1.1. Please check the right answer (check all that apply) The illness caused by a flu virus is worse in a pregnant woman compared to a woman who is not pregnant The flu can cause a very mild illness in a pregnant woman It is harmful for the baby if the mother receives a flu shot during pregnancy 1.2. Please check the right answer (check all that apply) A flu shot taken during pregnancy can be harmful for the baby A flu shot during pregnancy can protect the unborn baby A flu shot during pregnancy can protect the baby after birth A flu shot can protect a pregnant woman's life A flu shot puts a pregnant woman's life in danger Marital status 1.3. Please check the right answer (check all that apply) Married Folic acid intake is harmful for a pregnant woman Divorced Folic acid intake helps prevent some birth defects in the baby Widowed only if mom takes it for at least 3 months before getting pregnant Separated Folic acid should be taken by a pregnant woman before and Never married during the pregnancy Number of children in the household 1.4. Please check the right answer (check all that apply) Number of children Breastfeeding is harmful to mother s health None Breastfeeding is the beginning of healthy eating for the baby Breastfeeding builds a loving relationship between mom & baby Your highest grade in school Breastfeeding increases the risk of chronic disease in the baby Never attended school / only Kindergarten Breastfeeding is important for moms who cannot afford formula Grades 1 through 8 (Elementary) Breastfeeding reduces the chance of SIDS by 5% Grades 9 through 11 (Some high school) Grade 12 or GED (High school graduate) Some college / technical school College 4 years (College graduate or higher) 1.5. Please check the right answer (check all that apply) A baby should be laid down on his/her side to sleep A baby should be laid down on his/her stomach to sleep A baby should be laid down on his/her back to sleep Thank you for completing the Pre-Survey! 1.6. Please check the right answer (check all that apply) It is safer for a baby to sleep in the same bed as the parents It is safer for a baby to be wrapped in several blankets for sleep It is safer for a baby to sleep in their own crib Page 1
5 ADH OMHHD Sisters United Campaign Post Survey ( ) POST-SURVEY Participant Information Form (PIF) Please check the box(es) next to the right answer(s): UNIQUE ID #: To create your unique ID number, use the month of your birth, the day of your birth, and the last four digits of your social security number. For example, for May 29 and the ID number would be Unique ID: M M D D # # # # 1.1. Please check the right answer (check all that apply) The illness caused by a flu virus is worse in a pregnant woman compared to a woman who is not pregnant The flu can cause a very mild illness in a pregnant woman It harmful for the baby if the mother receives a flu shot during pregnancy 1.2. Please check the right answer (check all that apply) A flu shot taken during pregnancy can be harmful for the baby A flu shot during pregnancy can protect the unborn baby A flu shot during pregnancy can protect the baby after birth A flu shot can protect a pregnant woman's life A flu shot puts a pregnant woman's life in danger 1.3. Please check the right answer (check all that apply) Folic acid intake is harmful for a pregnant woman Folic acid intake helps prevent some birth defects in the baby only if mom takes it for at least 3 mo. Before getting pregnant Folic acid should be taken by a pregnant woman before and during pregnancy 1.4. Please check the right answer (check all that apply) Breastfeeding is harmful to mother s health Breastfeeding is the beginning of healthy eating for the baby Breastfeeding builds a loving relationship between mom & baby Breastfeeding increases the risk of chronic disease in the baby Breastfeeding is important for moms who cannot afford formula Breastfeeding reduces the chance of SIDS by 5% 1.5. Please check the right answer (check all that apply) A baby should be laid down on his/her side to sleep A baby should be laid down on his/her stomach to sleep A baby should be laid down on his/her back to sleep 1.6. Please check the right answer (check all that apply) It is safer for a baby to sleep in the same bed as the parents It is safer for a baby to be wrapped in several blankets for sleep It is safer for a baby to sleep in their own crib Thank you for completing the POST Survey! Page 2
6 SISTERS UNITED POST SURVEY-Sorority Leaders (6/212) 1. Unique ID Number ID Number: 1.% 2. Please check the correct answer (check all that apply) The illness caused by the flu virus is worse in a pregnant The flu can cause a very mild illness in a pregnant A flu shot can protect a pregnant woman's life. A flu shot can put a pregnant woman's life in danger. 77.8% % % 24.% 3. Please check the correct answer (check all that apply) A flu shot taken during pregnancy can be harmful for the A flu shot during pregnancy can protect an unborn baby A flu shot during pregnancy can protect the baby after A flu shot can protect a pregnant woman's life A flu shot puts a pregnant woman's life in danger.% 81.5% % % 5.% 4. Please check the correct answer (check all that apply) Folic acid intake is harmful for a pregnant Folic acid intake helps prevent some birth defects in the Folic acid should be taken by a pregnant woman before.% 66.7% % Please check the correct answer (check all that apply) Breastfeeding increases the risk of chronic disease in the Breastfeeding is harmful to the mother's health Breastfeeding is the beginning of healthy eating for the Breastfeeding builds a loving relationship between mom Breastfeeding is important for moms who cannot afford Breastfeeding reduces the chance of SIDS by 5% 7.4% 2.% 88.9% % % % 23 Page 3
7 6. Please check the correct answer (check all that apply) A baby should be laid down on his/her side to sleep A baby should be laid down on his/her stomach to sleep A baby should be laid down on his/her back to sleep.%.% 1.% 7. Please check the correct answer (check all that apply) It is safer for a baby to sleep in the same bed as the It is safer for a baby to be wrapped in several blankets for It is safer for a baby to sleep in their own crib.%.% 1.% Page 4
8 SU POST SURVEY Train-the-Trainer (2/213) 1. Unique ID Number ID Number: 1.% 2. Please check the correct answer (check all that apply) The illness caused by the flu virus is worse in a pregnant The flu can cause a very mild illness in a pregnant It is harmful for the baby if the mother receives a flu shot 85.5% % 1 3.6% Please check the correct answer (check all that apply) A flu shot taken during pregnancy can be harmful for the A flu shot during pregnancy can protect an unborn baby. A flu shot during pregnancy can protect the baby after A flu shot can protect a pregnant woman's life. A flu shot can put a pregnant woman's life in danger..% 96.6% % % 51.% 4. Please check the correct answer (check all that apply) Folic acid intake is harmful for a pregnant. Folic acid intake helps prevent some birth defects in the Folic acid should be taken by a pregnant woman before.% 81.% % Please check the correct answer (check all that apply) Breastfeeding increases the risk of chronic disease in the Breastfeeding is harmful to the mother's health. Breastfeeding is the beginning of healthy eating for the Breastfeeding builds a loving relationship between mom Breastfeeding is important for moms who cannot afford Breastfeeding reduces the chance of SIDS by 5%. 8.6% 5.% 96.6% % % % Please check the correct answer (check all that apply) Page 5
9 A baby should be laid down on his/her side to sleep. A baby should be laid down on his/her stomach to sleep. A baby should be laid down on his/her back to sleep..%.% 1.% 7. Please check the correct answer (check all that apply) It is safer for a baby to sleep in the same bed as the It is safer for a baby to be wrapped in several blankets for It is safer for a baby to sleep in their own crib..%.% 1.% Page 6
Cover Sheet for Example Documentation
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