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Respondent Information Form (RIF)

Local Public Health System Performance Assessment Instrument

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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. Which of the following best describes the organization or office to which your local public health officer reports directly?
(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. Is your jurisdiction completing the local public health system assessment as part of the MAPP (Mobilizing for Action through Planning
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.)

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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. During the assessment process, what type of decision making process was used?
(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. What process was used to complete the 10 sections of the assessment?
(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.

	A series of meetings during which one or two Essential Services were addressed at each meeting by the same group
throughout the entire process.
	A series of meetings during which one or two Essential Services were addressed at each meeting by a core group which
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:

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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
 nowledge of the public
K
health system
 nowledge of system
K
improvement needs
Intent 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
 oll-Free Helpline
T
(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

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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. As a result of completing the assessment, which of the following performance improvement steps do you expect to implement
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

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