NACDD 2017-2018 Peg Adams Peer to Peer Program Participation Form for Learners Survey

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* 1. Please tell us about yourself:

Name *

State *

Email Address

phone

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* 2. What is your responsibility in your state's 1305/1422 program? Please select all that apply.

	1305 Domain 3	1305 Domain 4	1422
Chronic Disease Director	Chronic Disease Director 1305 Domain 3	Chronic Disease Director 1305 Domain 4	Chronic Disease Director 1422
Program Manager/Domain Lead (eg: someone who has overarching responsibility and/or supervision of a whole domain or more)	Program Manager/Domain Lead (eg: someone who has overarching responsibility and/or supervision of a whole domain or more) 1305 Domain 3	Program Manager/Domain Lead (eg: someone who has overarching responsibility and/or supervision of a whole domain or more) 1305 Domain 4	Program Manager/Domain Lead (eg: someone who has overarching responsibility and/or supervision of a whole domain or more) 1422
Program Staff (eg: someone who has responsibilities in one or more strategies)	Program Staff (eg: someone who has responsibilities in one or more strategies) 1305 Domain 3	Program Staff (eg: someone who has responsibilities in one or more strategies) 1305 Domain 4	Program Staff (eg: someone who has responsibilities in one or more strategies) 1422
Epidemiologist	Epidemiologist 1305 Domain 3	Epidemiologist 1305 Domain 4	Epidemiologist 1422
Evaluator	Evaluator 1305 Domain 3	Evaluator 1305 Domain 4	Evaluator 1422
Other	Other 1305 Domain 3	Other 1305 Domain 4	Other 1422

If you selected Other, please specify your role

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* 3. Which one of the following content areas do you most want to focus on as a Learner in the Peer to Peer Program?

Cardiovascular Health

Diabetes

Epidemiology

Evaluation

Other

If you selected Other, please briefly describe:

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* 4. Consider where you find yourself getting “stumped” in the process of your work. Select your skill level in the listed skillset or topic.

	I am confident in this area	I have some skills, but would like to improve	I would like support in this area	I don't work in this area
Budget Planning	Budget Planning I am confident in this area	Budget Planning I have some skills, but would like to improve	Budget Planning I would like support in this area	Budget Planning I don't work in this area
Budget Management	Budget Management I am confident in this area	Budget Management I have some skills, but would like to improve	Budget Management I would like support in this area	Budget Management I don't work in this area
Work plan writing	Work plan writing I am confident in this area	Work plan writing I have some skills, but would like to improve	Work plan writing I would like support in this area	Work plan writing I don't work in this area
Work plan reporting	Work plan reporting I am confident in this area	Work plan reporting I have some skills, but would like to improve	Work plan reporting I would like support in this area	Work plan reporting I don't work in this area
Evaluation of the 1305/1422 work	Evaluation of the 1305/1422 work I am confident in this area	Evaluation of the 1305/1422 work I have some skills, but would like to improve	Evaluation of the 1305/1422 work I would like support in this area	Evaluation of the 1305/1422 work I don't work in this area
Epidemiology-related contributions to the 1305/1422 work	Epidemiology-related contributions to the 1305/1422 work I am confident in this area	Epidemiology-related contributions to the 1305/1422 work I have some skills, but would like to improve	Epidemiology-related contributions to the 1305/1422 work I would like support in this area	Epidemiology-related contributions to the 1305/1422 work I don't work in this area
Communications with CDC Project Officers	Communications with CDC Project Officers I am confident in this area	Communications with CDC Project Officers I have some skills, but would like to improve	Communications with CDC Project Officers I would like support in this area	Communications with CDC Project Officers I don't work in this area
Communication with internal partners	Communication with internal partners I am confident in this area	Communication with internal partners I have some skills, but would like to improve	Communication with internal partners I would like support in this area	Communication with internal partners I don't work in this area
Managing coalitions	Managing coalitions I am confident in this area	Managing coalitions I have some skills, but would like to improve	Managing coalitions I would like support in this area	Managing coalitions I don't work in this area
Coordination with other CDC-funded programs	Coordination with other CDC-funded programs I am confident in this area	Coordination with other CDC-funded programs I have some skills, but would like to improve	Coordination with other CDC-funded programs I would like support in this area	Coordination with other CDC-funded programs I don't work in this area

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* 5. What do you most want to learn or gain from this opportunity? Examples: how to act on or troubleshoot a specific strategy or activity in the work plan; how to use BRFSS data; how to write the work plan; how to navigate CDC evaluation requirements; how to plan for the new budget. It is OK if you are brand new and 'don't know what you don't know', you can input 'I don't know yet'.

Guides volunteer their time. Due to the volume of learners, there are not enough Guides to accommodate a one-on-one experience. Previous cohorts have found the group model with 2-3 Learners and a Guide to be beneficial. We are asking the question below to ensure you understand the basic format. Additional details will be provided at an orientation.

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* 6. I am willing to work in a group of two to three other Learners and a Guide and I understand this may mean agreeing on discussion topics and sharing the Guide's time.

Yes