Government Booklet B

Governance

Respondent Information Form (RIF)

Local Public Health Governance Performance Assessment Instrument

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Governance

Respondent Information Form (RIF)
Demographic Information
Board of Health or other Governing Body:
Address:
State:					
ZIP:					
Phone:						
Fax:
Presiding Officer:								
Email:
Health Commissioner/Officer:						
Email:

Email:

Contact Information for Board of Health if it is not the Governing Body:
Address:
State:					
ZIP:					
Phone:						
Fax:
Presiding Officer:								
Email:
Health Commissioner/Officer:						
Email:

Email:

1. Characteristics of local boards of health:
a.) Is your board (check all that apply):
	
Elected
	
Appointed
	
Designated
	
Other:
	
	
	
	
	

b.) If appointed and/or designated, by whom (check all that apply):
Mayor/City Council
County Commissioner
District/Regional Body
Other:

2. Which best describes the function of your board of health?
	
Advisory
	
Governing
3. How many people are employed in your health department?
	 Total FTEs:
4. For your current fiscal year, what is the total budget for:
	 a.) Your local public health agency?
	 b.) Board of heatlh training?
5. What is the population of your jurisdiction?
	 a. Population:
	 b. Year of population estimate:

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Local Public Health Governance Performance Assessment Instrument

Governance

About Your Site’s Assessment Process
Please tell us about your site’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.
6. During the assessment process, what type of decision making process was used? (check all that apply.)
	
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):
7. What process was used to complete the 10 sections of the assessment?
	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):
8. 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 Board of Health
The local health official
Other local health department staff:
Other:

9. 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

Local Public Health Governance Performance Assessment Instrument

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Governance

10. 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

11. How satisfied were you with the overall experience of the NPHPSP assessment process? (circle one)
Dissatisfied
1

Somewhat dissatisfied
2

Neutral
3

Somewhat satisfied
4

Satisfied
5

12. Would you complete the NPHPSP assessment process again?
	
	
	

Yes
No
Maybe

13. Please provide any additional comments on your experience with the NPHPSP process:

Next Steps: Performance Improvement
14. As a result of completing the assessment, which of the following performance improvement steps
do you expect to initiate in the next six months to address particular Essential Services or Model Standards?
	
	
	
	
	
	
	
	

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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 Governance Performance Assessment Instrument

N/A
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