Allies Against Asthma Eval Instruments

Allies Against Asthma
Evaluation Instruments
ALLIES AGAINST ASTHMA
EVALUATION INSTRUMENTS
Introduction
The enclosed instruments and tools were developed or adapted by Allies Against Asthma (Allies)
for the cross-site evaluation. A cover page describes each instrument and provides further
information to assist in the use or adaptation of these instruments by others. Appendix A
describes how Allies used these instruments in its cross-site evaluation.
The Allies Against Asthma program, funded by the Robert Wood Johnson Foundation, supports
seven coalitions which aim to develop and sustain community-wide pediatric asthma control
systems. Direction and technical assistance for Allies is provided by the National Program Office
at the University of Michigan. Allies’ evaluation approach was designed collaboratively by leaders
from all seven community coalitions, the program’s National Advisory Committee members and
the Allies National Program Office staff. Additional information about the program can be found
at www.AlliesAgainstAsthma.net.
Contents
Context Survey (English; 4 pages)
Purpose: to collect quantitative and qualitative information from coalition leaders about
coalition structure and functioning; the focus of coalition efforts; and the social, cultural
and political environment of the community in which the coalition operates
Coalition Self-Assessment Survey (CSAS) (English and Spanish; 21 pages each)

Purpose: to capture quantitative information from coalition members on coalition structure
and processes including coalition functioning, leadership, and effectiveness of effort
Key Informant Interview Guides (5 guides; English; total of 17 pages)

Purpose: to collect information on the activities of a coalition from its leaders and staff,
coalition members, and other community leaders who are not part of the coalition
Program Reach Forms (English; 9 pages)

Purpose: to document data on the extent of coalition activities
Core Caregiver Survey (English and Spanish; 10 pages each)

Purpose: to measure individual health outcomes of an intervention group and a
control/comparison group between baseline and follow-up periods
Appendix A: How Allies Used the Cross-site Evaluation Instruments (English; 3 pages)
Purpose: to explain how the instruments included in this toolkit were used in the Allies
cross-site evaluation
Allies Against Asthma is a national project supported by the Robert Wood Johnson Foundation. Direction and technical assistance
is provided by the National Program Office at the University of Michigan Center for Managing Chronic Disease.
CONTEXT SURVEY
Description
The Context Survey can be used to conduct a semi-structured interview to collect both
quantitative and qualitative information about coalition structure and functioning and the
focus of coalition efforts. It also gathers information about the social, cultural and political
environment of the community in which the coalition operates. The survey can be
administered to coalition members and staff as a telephone or face-to-face interview.
Development and Conditions of Use

Developed by Allies Against Asthma, 2003.
For use and/or adaptations of this document, please credit Allies Against Asthma.
Contact Information
Allies Against Asthma National Program Office
Center for Managing Chronic Disease
University of Michigan
109 South Observatory Street
Ann Arbor, MI 48109-2029
Phone: 734-615-3312
Fax: 734-763-7379
E-mail: asthma@umich.edu
www.AlliesAgainstAsthma.net
COALITION SELF-ASSESSMENT SURVEY (CSAS) CONTEXT SURVEY
Today’s date:
Coalition:
Names of interviewees:
Interviewer read: The purpose of this survey is to characterize the current environment, context, and
structure of your coalition
1. On what date did the 2nd follow-up administration of CSAS begin?
2. On what date did the follow-up period end?
3. How many members qualified for the first follow-up administration (attended two or more meetings in
the 12 months prior)?
4. Describe the non-responders.
5. What was the total number of respondents for the 2nd follow-up administration?
6. Briefly describe the major focus of coalition efforts:
Probe: Stage of development
7. How are decisions made within the coalition?

Probes: Brought to a general meeting? Made within committees, etc?
8. Please describe any changes to the structure of the coalition (e.g. organization of committees) at the
time of the second follow-up administration of CSAS.
Probe: Approximate number of individuals who serve on each of the committees.
9. During previous context interviews, we asked about a set of items1 related to specific characteristics of
coalition structure. We are interested if there have been any changes related to these characteristics at the
________________________________________________________________________________________________________________
Allies Against Asthma 5 Context Survey 2 of 5
present time. For each item, please indicate whether or not the characteristic was in place (yes), in
process, or not in place (no).
No In Process Yes
COALITION STRUCTURE
1 2 3
a. Bylaws/rules of operation
b. Mission statement in writing
c. Goals and objectives in writing
d. Regularly scheduled meetings
(with agendas)
Probe: who sets the agenda?
e. Effective communication
mechanisms (e.g. newsletters, minutes)
f. Organizational chart
g. Written job descriptions
h. Core planning group (e.g. steering or executive
committee)
i. Subcommittees
1. Butterfoss, F. D., Coalition Effectiveness Inventory (CEI) Self-Assessment Tool . Center for Pediatric Research; Center for Health Promotion,
South Carolina DHEC, 1994. Revised 1998.
10. Since the 2nd follow-up administration of CSAS, please describe any changes to the coalition’s
leadership:
Probes: How many are in leadership positions?

How are leaders chosen? (e.g. rotating schedule)
Are there opportunities for training new leaders?
Are incentives provided for those who take on leadership roles?
11. We would like to get a sense of the people with decision-making power within their organization
that are involved in or have influence on the coalition. They may or may not be “members” of the
coalition or go to meetings.
________________________________________________________________________________________________________________
Probes: If they do not come to coalition meetings, how do you get access to them?
Through another member, or through some other relationship?
“Some come to meeting and have direct decision making power on behalf of their organization --
Would people who are sitting at coalition meetings have access to their organization’s resources
so that they could come back to the coalition and commit resources on behalf of their
organization?”
Does the coalition have relationships outside of the coalition members that they go to, or do most
of the resources that come through the coalition come through the membership?
12. Please describe any changes over the past year to your coalition’s staffing:
Probes: How many? Background, skills?

How do staff view their role in the coalition? (e.g. sit on committees or staff committees)
13. Were there any changes to the role of the administrative agency in relationship to the coalition at
the time of the second follow-up administration of CSAS?
Probes:
-Does the administrative agency manage the finances on behalf of the coalition?
-Are they members of the coalition?
-Do they serve as facilitators or conveners of the coalition?
-Both?
Probes:
Do staff identify as:
-Staff of the coalition?
-Staff of the administrative agency?
-Both?
14. Were there any events in the previous that may have had a major impact on coalition dynamics?
Interviewer: Keep focused on big events and only on the year prior to CSAS first follow-up
administration.
Probe: Any disappointing events?
________________________________________________________________________________________________________________
15. Do you have any comments about the social, cultural, political, and/or economic environment
embedded in the community the coalition operates from around the time of the second follow-up
administration of CSAS?
16. Describe your stage of coalition readiness at this time.

(Readiness defined as having existing interoganizational networks, sense of trust, ability to come together
and make decisions, history of collaboration)
Probes:
How much of the work did the coalition have to do to try to create some of these relationships?
What changes occurred because of the coalition? If the coalition went away, what would be the readiness
in the community of some of these organizations to work together based on the work that the coalition has
done?
17. How do you think the work of the coalition for childhood asthma is different from stand-
alone programs?
18. Describe any lessons learned in terms of the coalition and its work.
19. Do you have any other comments that might help us understand the environment, structure
or context of your coalition at the time of the second follow-up administration of CSAS?
________________________________________________________________________________________________________________
COALITION SELF-ASSESSMENT SURVEY
Description
The Coalition Self-Assessment Survey (CSAS) can be used to capture quantitative information from
coalition members on coalition structure and processes including coalition functioning, leadership,
and effectiveness of effort. This document contains the English version and a Spanish translation.

Developed by Erin Kenney, Ph.D. and Shoshanna Sofaer, Dr.PH.
School of Public Affairs, Baruch College, City University of New York, 2000.
Adapted by Allies Against Asthma, 2002.
For use and/or adaptations of this document, please credit Erin Kenney, Ph.D. and Shoshanna
Sofaer, Dr.PH., School of Public Affairs, Baruch College, City University of New York, 2000.
Contact Information
Phone: 734-615-3312
Fax: 734-763-7379
COALITION
SELF-ASSESSMENT SURVEY

Second Follow-up
(Coalition Name)
For office use only
Site ID# _______
Administration Method:
(check one)
____ on-site during meeting

____ return by mail
____ visit to member
____ interviewer administered
Language:
(check one)
____ English
____ Spanish
Allies Against Asthma 5 Coalition Self-Assessment Survey (CSAS) 2 of 45

English version
INSTRUCTIONS FOR RESPONDENTS
Please answer questions as they pertain to the past year of your involvement or the time period
since joining the coalition within the past year.
Sample Question
S1. Please circle a number for each answer as in the sample answer:
1. no
2. yes
ROLE IN COALITION
Q1. What is your role in the coalition? Circle more than one response, if appropriate.
a. Member of the steering or executive committee

b. Coalition chair or officer
c. Chair/co-chair of a coalition committee or task force
d. Committee member
e. Member (no other responsibility)
f. Staff
g. Other________________________
Q2. Are you part of the coalition as an individual member or as a representative of an

organization? Please circle either 1 or 2, or both, if appropriate.
1. Individual Member, not representing an organization

2. Representative of an organization
3. Both
Q2a. If you are an individual member not representing an organization, please specify your role
(for example, “parent”)
_______________________
Q2b. If an individual member not representing an organization, how long have you been an
individual member of the coalition?
_____ YEARS _____MONTHS _____DON’T KNOW _____NOT APPLICABLE

English version
Q3. If you represent an organization, please indicate the one that best describes the organization
you represent in this coalition. Please circle only one.
1. Community Health Center/Community clinic

2. Community/neighborhood group
3. Ethnic and minority group organization
4. Youth organization
5. Parent organization
6. Women’s organization
7. Religious/Faith-based organization
8. Housing organization
9. Environmental advocacy group
10. Environmental agency
11. Voluntary agency that has asthma control as a key part of their mission
12. Other voluntary agency
13. Other community-based organization
14. Other coalition
15. After school program/Parks and recreation
16. Day care/Preschool/Head Start center
17. School (any grades K-12)
18. Academic institution (college/university)
19. HMO and other managed care organization
20. Medicaid and other insurers
21. Pharmaceutical company
22. Hospital
23. Health care provider organization (non-hospital)
24. Physician practice
25. Local health department
26. State health department
27. Business
28. Media
29. Legislative office
30. Other (please specify)__________________________________
31. None of the above
Q4. If a representative of an organization, how long has your organization been represented in
the coalition?
_____ YEARS _____MONTHS _____DON’T KNOW _____NOT APPLICABLE

English version
Q5. Please circle the role that fits you best. Circle only one.
1. Physician, please specify______________________________

2. Physician assistant
3. Nurse/nurse practitioner
4. Respiratory therapist
5. Social worker/case worker
6. Case manager
7. Community health worker
8. Outreach worker
9. Health educator
10. Other health professional, please specify__________________________
11. Day care/Head Start provider
12. After school/parks and recreation provider
13. Government official/staff
14. Parent/caregiver
15. Staff from non-profit
16. Administrator
17. Researcher/evaluator
18. Other, please specify_____________________________________
INCLUSION, RECRUITMENT, MEMBERSHIP
Q6. In your opinion, does your coalition have sufficient representation from groups,
organizations, and/or schools in your community to accomplish the objectives of the
coalition?
1. No
2. Yes
3. Don’t Know

English version
Q6a. If you answered “no” above, in your opinion, which type of the following groups,
organizations and/or schools listed are NOT well represented on the coalition? Circle all
that apply.
1. Community Health Center/Community clinic

2. Community/neighborhood council or advisory group
3. Ethnic and minority group organization
4. Youth organization
5. Parent organization
6. Women’s organization
7. Religious/Faith-based organization
8. Housing organization
9. Environmental advocacy group
10. Environmental agency
11. Voluntary agency that has asthma control as a key part of their mission
12. Other voluntary agency
13. Other community-based organization
14. Other coalition
15. After school program/Parks and recreation
16. Day care/Preschool/Head Start center
17. School K-12
18. Academic institution (college/university)
19. HMO and other managed care organization
20. Medicaid and other insurers
21. Pharmaceutical company
22. Hospital
23. Health care provider organization (non-hospital)
24. Physician practice
25. Local health department
26. State health department
27. Business
28. Media
29. Legislative office
30. Individuals with asthma
31. Parents/caregivers of children with asthma
32. Other (please specify)__________________________________
33. None of the above
Q6b. If you have circled one or more groups above as being not well represented, please select
the SINGLE group you think is most important to add to the coalition at this time.
Write the number of the group in this box:

English version
Q6c. Why do you think the group identified as most important to add to the coalition is not well
represented at this time? (CIRCLE ALL THAT APPLY):
1. The coalition never tried to involve them

2. The coalition invited them but they chose not to participate
3. They used to participate but dropped out
4. The coalition cannot get access to representatives of this group
5. The coalition as a whole is not sure that this group should be asked to join
6. Resources are lacking to recruit new members
7. Some coalition members do not want to share power with this group
8. Don’t know
Q7. Is your coalition actively recruiting new members?

1. No
2. Yes
3. Don’t know
Q8. In your opinion, do new members receive adequate orientation to be effective members of
the coalition?
1. No
2. Yes
3. Don’t know
Q9. Of those that represent organizations, please circle the number which best represents your
opinion about the number of members who participate in your coalition who have
enough authority to make commitments of resources or other support for the coalition.
1. Less than one-quarter of the members

2. Less than half of the members
3. More than half of the members
4. Nearly all of the members
5. Doesn’t apply/Don’t know

English version
DECISION-MAKING, CONFLICT RESOLUTION
Q10. Please circle the number below that shows how much influence you think the person or
group has in deciding on the actions and policies for your coalition.
No Some A Lot of Not

Influence Influence Influence Applicable
a) Coalition Chair 1 2 3 4
b) Coalition Officers or Committee Chairs 1 2 3 4
c) Lead Staff 1 2 3 4
d) Coalition Members 1 2 3 4
Q11. Please circle a number to show how much influence you personally have in making
coalition decisions.
No Influence Some Influence A Lot of Influence
1 2 3
Q12. How are decisions usually made regarding coalition priorities, policies and actions?
Circle the number of the main way(s) you think decisions are usually made.
(CIRCLE NO MORE THAN TWO):
1. Coalition members vote, with majority rule

2. Coalition members discuss the issue and come to consensus
3. The coalition chair makes final decisions
4. The coalition executive or steering committee makes final decisions
5. The lead agency for the project makes the decisions
6. Don’t know
Q13. Please circle a number to show how comfortable you are overall with the coalition
decision-making process.
Not at All Somewhat Very

Comfortable Comfortable Comfortable
1 2 3

English version
Q14. Please circle a number to show how much you agree or disagree with the following
statements.
Strongly Disagree Agree Strongly Don’t

Disagree Agree Know
a) The coalition has clear and explicit procedures for 1 2 3 4 5

making important decisions
b) The coalition follows standard procedures for 1 2 3 4 5

making decisions
c) The decision-making process used by the coalition is 1 2 3 4 5

fair
d) The decision-making process used by the coalition is 1 2 3 4 5

timely
e) The coalition makes good decisions 1 2 3 4 5
Q14a. Circle the number that represents the amount of conflict in your coalition.
1. More conflict than I expected

2. Less conflict than I expected
3. About as much conflict as I expected

English version
Q14b. Circle the number that best represents your opinion of how much conflict within the
coalition was caused by each of the following factors:
None Some A Lot Don’t

Know
a) Differences in opinion about coalition mission and goals 1 2 3 4
b) Differences in opinion about specific objectives 1 2 3 4
c) Differences in opinion about the best strategies to achieve 1 2 3 4

coalition goals and objectives
d) Personality clashes 1 2 3 4
e) Fighting for power, prestige and/or influence 1 2 3 4
f) Fighting for resources 1 2 3 4
g) Differences in opinion about who gets public exposure and 1 2 3 4

recognition
h) Procedures used for completing the work 1 2 3 4
i) People aren’t sufficiently included in coalition 1 2 3 4

processes/decision-making
j) Member(s) who dominate the coalition meetings and 1 2 3 4
impede proper collaboration
Q15. Please circle the main strategy your coalition has used to address conflicts that occur.
(CIRLCE NO MORE THAN TWO):
1. Open debate about opposing viewpoints

2. Postponing or avoiding discussions of controversial issues
3. Having a third party mediate between those with opposing viewpoints
4. Having the opposing parties negotiate directly with each other
5. One party to the conflict gives in
6. Don’t know

English version
LEADERSHIP, STAFFING, RELATIONSHIPS
Q16. Who do you think is most significant in providing leadership for your coalition?
(CIRCLE ONLY ONE NUMBER):
1. Coalition Chair
2. Coalition Officers or Committee Chairs
3. Lead Staff
4. Coalition Members
5. Other
6. Don’t Know

English version
Q17. With respect to the leadership you just identified, please circle a number to show how
much you agree or disagree with the following statements.

The leadership of our coalition: Disagree Agree Know
a) Has a clear vision for the coalition 1 2 3 4 5
b) Is respected in the community 1 2 3 4 5
c) Gets things done 1 2 3 4 5
d) Is respected in the coalition 1 2 3 4 5
e) Controls decisions 1 2 3 4 5
f) Intentionally seeks other’s views 1 2 3 4 5
g) Utilizes the skills and talents of many, not 1 2 3 4 5

just a few
h) Creates an appropriate balance of 1 2 3 4 5

responsibility between leaders, staff and
embers
i) Advocates strongly for its own opinions 1 2 3 4 5
and agendas
j) Builds consensus on key decisions 1 2 3 4 5
k) Works collaboratively with coalition 1 2 3 4 5

members
l) Controls discussions 1 2 3 4 5
m) Keeps the coalition focused on tasks and 1 2 3 4 5

objectives
n) Is skillful in resolving conflict 1 2 3 4 5
o) Is ethical 1 2 3 4 5

English version
Q18. Who actually sets the agenda for meetings of the coalition and its committee/task forces?
(PLEASE CIRCLE ALL THAT APPLY):
1. Coalition Chair
2. Coalition Officers or Committee Chairs
3. Lead Staff
4. Coalition Members
5. Don’t know
Q19. Please circle a number to show how much you agree or disagree with each statement.

Disagree Agree Know
a) The coalition is well managed 1 2 3 4 5
b) The work of the paid staff supports 1 2 3 4 5

the work of the coalition
c) People know the roles of staff as 1 2 3 4 5

compared to coalition members
d) Coalition members take responsibility 1 2 3 4 5

for getting the work done

English version
Q20. Please circle a number to show whether the following functions are major, minor, not a
function, or you don’t know.
The functions of our coalition are to:
Not a A Minor A Major Don’t Know

Function Function Function
a) Network with other professionals 1 2 3 4
b) Network with concerned citizens 1 2 3 4
c) Conduct strategic planning 1 2 3 4
d) Make decisions about priority needs and 1 2 3 4

problems
e) Recommend or make decisions to allocate 1 2 3 4

resources
f) Operate particular programs or activities 1 2 3 4
g) Advocate for local public policy objectives 1 2 3 4
h) Advocate for state public policy objectives 1 2 3 4
i) Provide funding for current programs 1 2 3 4
j) Raise funds to sustain long-term coalition 1 2 3 4

activities

English version
TRUST1
statements.

Disagree Agree Know
a) Relationships among coalition members go 1 2 3 4 5
beyond individuals at the table, to include
member organizations
b) I am comfortable requesting assistance from 1 2 3 4 5
the other coalition members when I feel their
input could be of value
c) I can talk openly and honestly at the coalition 1 2 3 4 5
meetings
d) I am comfortable expressing my point of view 1 2 3 4 5

even if they might disagree
e) I am comfortable bringing up new ideas at 1 2 3 4 5

coalition meetings
f) Coalition members respect each others’ points 1 2 3 4 5

of view even if they might disagree
g) My opinion is listened to and considered by 1 2 3 4 5

other members
1. References:
Israel B.A., Schurman S.J., House J.S. Action research on occupational stress: involving workers as researchers.
International Journal of Health Services 19(1): 135-155, 1989.
Israel B.A., Lantz P.M., McGranaghan, R.J., Kerr, D.L., Guzman, J.R. Documentation and evaluation of CBPR
partnerships: In-depth interviews and closed-ended questionnaires. In Methods in Community-Based Participatory
Research for Health Israel, B.A., Eng E., Schulz, A.J., Parker, E.A., eds. John Wiley & Sons, San Francisco, CA,
225-283, 2005.
Israel B.A., Lantz P.M., McGranaghan, R.J., Kerr, D.L., Guzman, J.R. Detroit Community-Academic Urban
Research Center. Closed-ended survey questionnaire for board evaluation, 1997-2002. In Methods in Community-
Based Participatory Research for Health Israel, B.A., Eng E., Schulz, A.J., Parker, E.A., eds. John Wiley & Sons,
San Francisco, CA, 430-433, 2005.

English version
MISSION STRATEGIES AND ACTION PLANS
statements.

Disagree Agree Know
a) Our coalition has a clear and shared 1 2 3 4 5
understanding of the problems we are
trying to address
b) There is a general agreement with respect 1 2 3 4 5

to the mission of the coalition
c) There is general agreement with respect to 1 2 3 4 5

the priorities of the coalition
d) Members agree on the strategies the 1 2 3 4 5

coalition should use in pursuing its
priorities
e) Our action plan defines well the roles, 1 2 3 4 5

responsibilities and timelines for
conducting the activities that work
towards achieving the stated mission of
the coalition
statements.

Disagree Agree Know
a) Notification of meetings is timely 1 2 3 4 5
b) Background materials needed for meetings 1 2 3 4 5

are prepared & distributed in advance of
meetings (agendas, minutes, study
documents)
c) Informative committee and/or task force 1 2 3 4 5
reports are routinely made to the entire
coalition

English version
PARTICIPATION
Q24. Over the past year, how involved have you been in coalition activities?
1. Not at all involved

2. A little involved
3. Fairly involved
4. Very involved
Q25. Please circle a number to show how many times over the last year you personally have
done the following for the coalition:
Never Rarely (1-2 Sometimes Often (5+ Not

times) (3-4 times) times) Applicable
a) Recruited new members 1 2 3 4 5
b) Served as a spokesperson 1 2 3 4 5
c) Attempted to get outside support for 1 2 3 4 5

coalition positions on key issues
d) Worked on implementing activities or 1 2 3 4 5

events sponsored by the coalition (other
than coalition meetings)
e) Acquired funding or other resources for 1 2 3 4 5
the coalition
statements:

Disagree Agree Know
a) I feel that I have a voice in what the coalition 1 2 3 4 5

decides
b) I go to coalition meetings only because it is 1 2 3 4 5

part of my job
c) I am satisfied with how the coalition operates 1 2 3 4 5
d) I feel a strong sense of “loyalty” to the 1 2 3 4 5

coalition

English version
statements. If you consider yourself an individual member (and circled #1 in Q2), please do
not answer this question and go to question Q28.

Disagree Agree Know
a) Staff from my organization contribute time to the 1 2 3 4 5

coalition
b) Volunteers from my organization contribute time 1 2 3 4 5

to the coalition
c) My organization supports the positions of the 1 2 3 4 5

coalition publicly
d) Overall, my organization is committed to the work 1 2 3 4 5

of the coalition
e) My organization contributes funds to support the 1 2 3 4 5

coalition
Q28. Please circle a number to show to what extent each of the following has been a benefit to
your participation or your organization’s participation on the coalition.
No Benefit A Little Some Great Not

Benefit Benefit Benefit Applicable
a) Developing collaborative relationships with 1 2 3 4 5
other agencies
b) Helping my organization move toward our 1 2 3 4 5
goals
c) Getting access to target populations with 1 2 3 4 5
whom we have previously had little contact
d) Getting funding for my organization 1 2 3 4 5
e) Getting services for our clients 1 2 3 4 5
f) Getting client referrals from others 1 2 3 4 5
g) Increasing my professional skills and 1 2 3 4 5

knowledge
h) Staying well informed in a rapidly changing 1 2 3 4 5
environment
i) Getting access to key policy makers 1 2 3 4 5
j) Increasing my sense that others share my 1 2 3 4 5

goals and concerns
k) Getting support for policy issues our 1 2 3 4 5
organization feels strongly about

English version
Q29. Please circle a number to show to what extent each of the following have been problems
for your participation or your organization’s participation in the coalition.
No Minor A Major Not

Problem Problem Problem Applicable
a) Coalition activities do not reach my primary 1 2 3 4

constituency
b) My organization doesn’t get enough public 1 2 3 4

recognition for our work on the coalition
c) Being involved in policy advocacy is a problem 1 2 3 4
d) My skills and time are not well-used 1 2 3 4
e) My (or my organization’s) opinion is not valued 1 2 3 4
f) The coalition is not taking any meaningful action 1 2 3 4
g) I am often the only voice representing my 1 2 3 4

viewpoint
h) The financial burden of traveling to coalition
meetings is too high 1 2 3 4
i) The financial burden of participating in coalition

activities (barring travel) is too high 1 2 3 4
j) The coalition is competing with my organization 1 2 3 4
Q30. From your organization’s perspective (if applicable), do the benefits of participation in
the coalition appear to outweigh the costs at this point?
1. No
2. Yes
3. I do not represent an organization on the coalition
Q31. From your own professional and/or personal perspective, do the benefits of participation in
the coalition appear to outweigh the costs at this point?
1. No
2. Yes
3. Don’t know

English version
COMMUNICATION
statements.

Disagree Agree Know
a) The current method for communication 1 2 3 4 5
between coalition staff/leadership and its
members is effective
b) Members can communicate between 1 2 3 4 5
themselves as necessary or desired
c) The coalition staff facilitates communication 1 2 3 4 5

between coalition members
d) The coalition staff effectively and efficiently 1 2 3 4 5

notifies me of meetings, agenda items, etc.
ASTHMA KNOWLEDGE
Q33. Do you feel you have adequate knowledge about childhood asthma to function effectively
in the coalition?
1. No
2. Yes
Q34. Has the coalition helped you learn more about childhood asthma?
1. No
2. Yes
COALITION MATURITY, READINESS, SUSTAINABILITY
Q35. Has your coalition been responsible for activities or programs that
otherwise would not have occurred?
1. No
2. Yes
3. Don’t know

English version
Q36. Has your coalition brought benefit to your community?
1. No
2. Yes
3. Don’t know
statements.

Disagree Agree Know
a) The coalition is making progress in 1 2 3 4 5
implementing the activities that have potential
to improve childhood asthma.
b) The coalition is improving health outcomes for 1 2 3 4 5
children with asthma.
statements.

Disagree Agree Know
a) The coalition is making plans to continue 1 2 3 4 5
operating after current funding is terminated
b) The coalition has begun to find resources to 1 2 3 4 5

continue operating after current funding is
terminated
c) Resources are being identified to support the 1 2 3 4 5
systemic, programmatic changes implemented
through the work of the coalition
d) The coalition will continue to exist beyond the 1 2 3 4 5
Robert Wood Johnson Foundation grant period

English version
statements.

Disagree Agree Know
a) The coalition is essential to the improvement 1 2 3 4 5
of pediatric asthma
b) One or a small number of people or agencies 1 2 3 4 5

could make significant progress in pediatric
asthma without the coalition
c) In general I am satisfied with the coalition 1 2 3 4 5
Q40. What issues should the coalition leadership and staff be paying more attention to?
Q41. Are there any critical events over the past year that have had an impact on the coalition?
Please describe.

English version
Standard Section on Demographics of Respondents
D1. Your gender:
1. Female
2. Male
D2. Your Race or Ethnicity:
1. African American/Black
2. White
3. Asian American
4. Native Hawaiian or other Pacific Islander
5. Native American
6. Latino or Hispanic
If Latino or Hispanic, do you consider yourself:
6.1. Puerto Rican/ “Newyorrican”
6.2. Mexican/Mexican American/Chicano
6.3. Cuban/Cuban American
6.4. Dominican
6.5. Other Spanish-Caribbean
6.6. Central American
6.7. South American
6.8. Other Latino/Hispanic (please specify): _____________
7. Other Race or Ethnicity (please specify): _____________
D3. Your age at last birthday:
_____ YEARS
D4. Your education:
1. Grade 6 or less
2. Grade 7 or 8
3. Some high school
4. Graduated from high school
5. Graduated from technical or vocational school
6. Some college
7. Graduated from college
8. Some graduate school
9. Completed graduate school
D5. Did you complete this survey when it was administered a year ago?
1. No
2. Yes
3. Don’t Know

English version
ENCUESTA DE
AUTO-EVALUACION DE
LA COALICIÓN
Segunda Encuesta de Auto-evaluacion de la coalición
Para uso de la oficina solamente
Número de Identificación del Lugar/”Site” _____________
Método de Administración: (marque uno)
_____ En una reunión local

_____ Devuelto por correo
_____ Visita a miembro
_____ Administrado por encuestador/a
Idioma (marque uno)

_____ Inglés
_____ Español
Fecha Entregado _____________________

Fecha Completado ____________________

Spanish version
INSTRUCCIONES PARA LOS/AS ENCUESTADOS/AS
Por favor conteste las preguntas que corresponden al último año de su participación, o al período
dentro de ese año que Ud. se hizo miembro de la coalición.
Ejemplo de preguntas
S1. Por favor circule el número para cada respuesta basándose en este ejemplo:
1. No
2. Sí
ROL EN LA COALICION
Q1. ¿Cuál es su rol en la coalición? Circule más de una respuesta si aplica.
a. Miembro de la junta/mesa directiva o comité ejecutivo

b. Presidente u oficial de la coalición
c. Presidente/co-presidente o Director/co-director de un comité de la coalición o “task
force”
d. Miembro de algún comité
e. Miembro (no tiene otra responsabilidad)
f. Personal/Empleado/a
g. Otro
Q2. ¿Es Ud. parte de la coalición como miembro individual o como representante de una
organización? Por favor circule el 1, el 2 ó ambos, si aplica.
1. Miembro individual, no representa una organización

2. Representante de una organización.
3. Ambos
Q2a. Si es usted miembro individual, que no representa una organización, por favor especifique
su rol. (por ejemplo, padre/madre/encargado) __________________________________
Q2b. Si es un miembro individual, que no representa una organización, ¿hace cuánto tiempo ha
sido miembro individual de la coalición?
_____ AÑOS _____ MESES _____ NO SE/NO SABE _____ NO APLICA

Spanish version
Q3. Si representa una organización, por favor indique la que mejor describe la organización que
usted representa en la coalición. Por favor circule solo una alternativa.
32. Centro de Salud de la Comunidad/Clínica de la Comunidad

33. Consejo Vecinal/Comunitario o Grupo de Asesores
34. Organización de Grupos Étnicos y Minoritarios
35. Organización de Jóvenes
36. Organización de Padres
37. Organización de Mujeres
38. Organización Religiosa/ o de Fé
39. Organización de Vivienda
40. Group Defensor del Ambiente
41. Agencia Ambiental
42. Agencia de Voluntarios que tenga el control del asma como una parte clave de su misión
43. Otra Agencia de Voluntarios
44. Otra Organización de Base Comunitaria
45. Otra Coalición
46. Programa de Horario Extendido en la escuela o de Parques y Recreación
47. Cuidado Diurno de Niños/Centros Head Start/Pre-escolar
48. Escuelas de Kinder a Duodécimo Grado (12)
49. Institución Académica (colegio/universidad)
50. HMO y otras Organizaciones de Cuidado Dirigido o Coordinado
51. Medicaid y otras aseguradoras
52. Compañía Farmacéutica
53. Hospital
54. Organización que provee Cuidado de Salud (no hospitalaria)
55. Práctica médica
56. Departamento de Salud Local
57. Departamento de Salud Estatal
58. Negocio
59. Medios de Comunicación
60. Oficina Legislativa
61. Otro (por favor especifique)____________________________
62. Ninguna de las anteriores
Q4. Si Ud. representa una organización, ¿hace cuánto tiempo que su organización está
representada en la coalición?
_____ AÑOS _____MESES _____ NO SABE/NO SÉ _____NO APLICA

Spanish version
Q5. Por favor, circule el rol que mejor le describe. Circule solo una alternativa, por favor.
a. Médico, por favor especifique ____________________________
b. Asistente médico
c. Enfermera/ “Nurse practitioner”
d. Terapista respiratorio
e. Trabajador social/Trabajador de casos
f. Manejador de casos
g. Trabajador de salud comunitario/“Community Health Worker”
h. Trabajador de alcance comunitario/“Outreach worker”
i. Educador en Salud
j. Otro profesional de la salud, por favor especifique ___________________
k. Cuidado Diurno de Niños/Proveedor de Head Start
l. Proveedor de Horario Extendido en la escuela o de Parques y Recreación
m. Oficial/Personal gubernamental
n. Padre/Madre/Encargado
o. Personal de Organización sin fines de lucro
p. Administrador/a
q. Investigador(a)/Evaluador(a)
r. Otro, por favor especifique ________________________________
INCLUSIÓN, RECLUTAMIENTO, MEMBRESÍA
Q6. En su opinión, ¿tiene su coalición suficiente representación de grupos, organizaciones, y/o

escuelas de la comunidad para lograr los objetivos de la coalición?
1. No
2. Sí
3. No sabe/No sé
Q6a. Si contesto no en la pregunta anterior en su opinión, ¿cuáles de los siguientes grupos,

organizaciones y/o escuelas listados NO están bien representados en la coalición?
(Circule todas las que apliquen)
1. Centro de Salud de la Comunidad/Clínica de la Comunidad
2. Consejo Vecinal/Comunitario o Grupo de Asesores
3. Organización de Grupos Étnicos y Minoritarios
4. Organización de Jóvenes
5. Organización de Padres
6. Organización de Mújeres
7. Organización Religiosa/ o de Fé
8. Organización de vivienda
9. Group Defensor del Ambiente

Spanish version
10. Agencia Ambiental
11. Agencia de Voluntarios que tenga el control del asma como una parte clave de su misión
12. Otra Agencia de Voluntarios
13. Otra Organización de base comunitaria
14. Otra Coalición
15. Programa de Horario Extendido en la escuela o de Parques y Recreación
16. Cuidado Diurno de Niños/Centros Head Start/Pre-escolar
17. Escuela de Kinder a Duodécimo Grado (12)
18. Institución Académica (Colegio/Universidad)
19. HMO y otras Organizaciones de Cuidado Dirigido o Coordinado
20. Medicaid y otras aseguradoras
21. Compañía Farmaceútica
22. Hospital
23. Organización que provee Cuidado de Salud (no hospitalaria)
24. Práctica médica
25. Departamento de Salud Local
26. Departamento de Salud Estatal
27. Negocio
28. Medios de Comunicación
29. Oficina Legislativa
30. Persona con asma
31. Padre/Madre/Encargado de niños/as con asma
32. Otro (Por favor especifique)_____________________________________________
33. Ninguna de los anteriores
Q6b. Si Ud. ha circulado uno o más de los grupos mencionados arriba como uno que no
está bien representado, por favor seleccione SOLO UN grupo que usted piensa
sea el más importante para ser incluido en la coalición en este momento.
Escriba el número del grupo en este encasillado:
Q6c. ¿Por qué piensa Ud. que el grupo identificado como el más importante para incluir
en la coalición no está bien representado en este momento? (Circule todos los que
apliquen):
1. La coalición nunca trató de involucrarlos

2. La coalición los invitó pero ellos decidieron no participar
3. Participaban pero dejaron de hacerlo
4. La coalición no puede obtener acceso a los representantes de este grupo
5. La coalición en pleno no está segura de pedirle a este grupo que participe
6. Faltan recursos para reclutar nuevos miembros
7. Algunos miembros de la coalición no desean compartir poder con este grupo
8. No sabe/No sé

Spanish version
Q7. ¿Está su coalición reclutando activamente miembros nuevos?
1. No
2. Sí
3. No sabe/No sé
Q8. En su opinión, ¿reciben los miembros nuevos una orientación adecuada para ser miembros
efectivos de la coalición?
1. No
2. Sí
3. No sabe/No sé
Q9. De aquellos que representan organizaciones, por favor circule el número que representa
mejor su opinión acerca del número de miembros que participan en su coalición y que
tienen suficiente autoridad para comprometer recursos u otro apoyo para la coalición:
1. Menos de una cuarta parte de los miembros
2. Menos de la mitad de los miembros
3. Más de la mitad de los miembros
4. Casi todos los miembros
5. No aplica/No sabe/No sé
TOMA DE DECISIONES, RESOLUCIÓN DE CONFLICTOS
Q10. Por favor circule abajo el número que indique cuánta influencia usted cree tiene la
persona o grupo en tomar decisiones sobre acciones y políticas para su coalición.
Ninguna Alguna Mucha No Aplica
Influencia Influencia Influencia
a) Presidente/Director de la coalición 1 2 3 4
b) Oficiales de la coalición o 1 2 3 4
presidentes/directores de los comités
c) Personal directivo 1 2 3 4
d) Miembros de la coalición 1 2 3 4
Q11. Por favor circule el número que indique cuanta influencia Ud. tiene personalmente en la
toma de decisiones de la coalición:
Ninguna Influencia Alguna Influencia Mucha Influencia
1 2 3

Spanish version
Q12. Por lo general, ¿cómo se toman las decisiones relacionadas a las prioridades, políticas y
acciones de la coalición? Circule el número que corresponda a la/s manera/s principal/es
en las que Ud. piensa se toman por lo general estas decisiones:
(NO CIRCULE MAS DE DOS):
1. Los miembros de la coalición votan con regla de mayoría

2. Los miembros de la coalición discuten el asunto y llegan a un consenso
3. El presidente/director de la coalición toma las decisiones finales
4. La junta directiva o el comité ejecutivo de la coalición toma la decisiones finales
5. La agencia líder del proyecto toma las decisiones
6. No sabe/No sé
Q13. Por favor circule el número que indique cuan cómodo Ud. está generalmente con el
proceso de toma de decisiones de la coalición:
Nada cómodo Algo cómodo Muy cómodo
1 2 3
Q14. Por favor circule el número que indique cuanto Ud. está de acuerdo o en desacuerdo con
lo siguiente:
Firmemente En De Firme- No sabe/

en desacuerdo acuerdo mente de No sé
desacuerdo acuerdo
b) La coalición tiene procedimientos claros y 1 2 3 4 5

explícitos para tomar decisiones importantes
b) La coalición sigue procedimientos estandarizados 1 2 3 4 5

para tomar decisiones
c) El proceso de toma de decisiones utilizado por la 1 2 3 4 5

coalición es justo
d) El proceso de toma de decisiones utilizado por la 1 2 3 4 5

coalición se lleva a cabo a tiempo
e) La coalición toma buenas decisiones 4 5

1 2 3

Spanish version
Q14a. Por favor circule el número que represente la cantidad de conflicto en su coalición:
1. Más conflicto del que esperaba

2. Menos conflicto del que esperaba
3. Más o menos la cantidad de conflicto que esperaba
Q14b. Por favor circule el número que mejor represente su opinión de cuanto conflicto dentro
de la coalición fue causado por cada uno de estos factores:
Ninguno Alguno Mucho No sabe/

No sé
j) Diferencias de opinión acerca de la misión y metas de la 1 2 3 4

coalición
k) Diferencias de opinión con relación a objetivos específicos 1 2 3 4
l) Diferencias de opinión sobre las mejores estrategias para 1 2 3 4

alcanzar las metas y los objetivos de la coalición
m) Choque de personalidades 1 2 3 4
n) Enfrentamientos de poder, prestigio y/o influencia 1 2 3 4
o) Enfrentamientos por recursos 1 2 3 4
p) Diferencias de opinión acerca de quién obtiene exposición 1 2 3 4

pública y reconocimiento
q) Procedimientos utilizados para completar el trabajo 1 2 3 4
r) Las personas no están suficientemente incluidas en los 1 2 3 4

procesos/toma de decisiones de la coalición
j) Miembro(s) que dominan las reuniones de la coalición e
impiden colaboración propia 1 2 3 4
Q15. Por favor circule la estrategia principal que su coalición ha utilizado para manejar
conflictos que suceden.
(NO CIRCULE MÁS DE DOS):
1. Debate abierto sobre puntos de vista opuestos
2. Posponiendo o evitando discusiones sobre asuntos controversiales
3. Teniendo una tercera persona para actuar como mediador entre aquellos con puntos de
vista opuestos
4. Haciendo que las partes en conflicto lleguen a negociar directamente una con la otra
5. Una de las partes en conflicto cede
6. No sabe/No sé

Spanish version
LIDERATO, PERSONAL, RELACIONES
Q16. ¿Quién cree Ud. es la persona más significativa en ejercer liderato para su coalición?
(CIRCULE SOLO UN NÚMERO):
1. Presidente/Director de la coalición
2. Oficiales de la coalición o los presidentes/directores de los comités
3. Personal directivo
4. Miembros de la coalición
5. Otro(s)
6. No sabe/No sé

Spanish version
Q17. En relación al liderato que Ud. acaba de identificar, por favor circule el número que
indique cuanto está de acuerdo o en desacuerdo con lo siguiente:
Firmemente En De acuerdo Firmemente No sabe/
El liderato de nuestra coalición: en desacuerdo de acuerdo No sé
Desacuerdo
p) Tiene una visión clara para la coalición 4

1 2 3 5
q) Es respetado/a dentro de la comunidad 3 4 5

1 2
r) Logra que se hagan las cosas 3 4 5

1 2
s) Es respetado/a en la coalición 3 4 5
1 2
t) Controla las decisiones 3 4 5

1 2
u) Busca la opinión de otros 3 4 5

intencionalmente 1 2
v) Utiliza las habilidades y talentos de 3 4 5

muchos, no solo de algunos 1 2
w) Crea un balance apropiado de

responsabilidades entre los líderes, el 1 2 3 4 5
personal y los miembros
x) Aboga fuertemente por sus propias 3 4 5
opiniones y agendas 1 2
y) Crea consenso sobre decisiones claves 3 4 5

1 2
z) Trabaja en colaboración con los miembros 3 4 5

de la coalición 1 2
aa) Controla las discusiones 3 4 5

1 2
bb) Mantiene la coalición enfocada en las 3 4 5

tareas y objetivos 1 2
cc) Es hábil en resolver conflictos 3 4 5

1 2
dd) Es ético/a 3 4 5
1 2

Spanish version
Q18. ¿Quién realmente determina la agenda para las reuniones de la coalición y de sus
comités/ “task forces”?
(FAVOR CIRCULE TODOS LOS QUE APLIQUEN):
1. Presidente/Director de la coalición
2. Oficiales de la coalición o los presidentes/directores de los comités
3. Personal directivo
4. Miembros de la coalición
5. No sabe/No sé
Q19. Por favor circule el número que indique cuanto está de acuerdo o en desacuerdo con lo
siguiente:

desacuerdo acuerdo
e) La coalición está bien administrada 5

1 2 3 4
f) El trabajo del personal asalariado 5

1 2 3 4
apoya el trabajo de la coalición
g) Las personas conocen el rol del

5
personal en comparación con los 1 2 3 4
miembros de la coalición
h) Los miembros de la coalición asumen

5
la responsabilidad de cumplir con el 1 2 3 4
trabajo

Spanish version
Q20. Por favor circule el número que indique si las siguientes funciones son de mayor o menor
importancia, si no son una función o si no sabe:
Las funciones de nuestra coalición son:
No es una Menor Mayor No sabe/
función impor- impor- No sé
tancia tancia
a) Intercambio con otros profesionales 1 2 3 4
b) Intercambio con ciudadanos interesados 1 2 3 4
c) Dirigir la planificación estratégica 1 2 3 4
d) Tomar decisiones acerca de las necesidades y los 1 2 3 4

problemas que tienen prioridad
e) Recomendar o tomar decisiones sobre la distribución 1 2 3 4
de recursos
f) Operar/dirigir programas o actividades específicas 1 2 3 4
g) Abogar por objetivos de política pública local 1 2 3 4
h) Abogar por objetivos de política pública del estado 1 2 3 4
i) Proveer fondos para mantener programas vigentes 1 2 3 4
j) Recaudar fondos para mantener las actividades de la 1 2 3 4

coalición a largo plazo

Spanish version
CONFIANZA1
Q21. Por favor circule el número que indique cuanto Ud está de acuerdo o en desacuerdo con lo
siguiente:
Firmemente En De Firmemente No sabe/

en desacuerdo desacuerdo acuerdo de acuerdo No sé
a) Las relaciones entre miembros de la
coalición van más allá de los individuos 5
1 2 3 4
en la mesa de negociaciones para incluir a
organizaciones miembros
b) Me siento cómodo/a pidiendo ayuda a
otros miembros de la coalición cuando 1 2 3 4 5
pienso que su insumo puede ser valioso
c) Puedo hablar abierta y honestamente en
1 2 3 4
las reuniones de la coalición 5
d) Me siento cómodo/a cuando expreso mi
punto de vista aún cuando otros no estén 1 2 3 4 5
de acuerdo
e) Me siento cómodo/a planteando nuevas
1 2 3 4
ideas en las reuniones de la coalición 5
f) Los miembros de la coalición respetan los
puntos de vista de otros aún cuando no 1 2 3 4 5
estén de acuerdo
g) Los otros miembros escuchan mi opinión y
1 2 3 4
la consideran 5
1. References:
Israel B.A., Schurman S.J., House J.S. Action research on occupational stress: involving workers as researchers.
International Journal of Health Services 19(1): 135-155, 1989.
Israel B.A., Lantz P.M., McGranaghan, R.J., Kerr, D.L., Guzman, J.R. Documentation and evaluation of CBPR
partnerships: In-depth interviews and closed-ended questionnaires. In Methods in Community-Based Participatory
Research for Health Israel, B.A., Eng E., Schulz, A.J., Parker, E.A., eds. John Wiley & Sons, San Francisco, CA,
225-283, 2005.
Israel B.A., Lantz P.M., McGranaghan, R.J., Kerr, D.L., Guzman, J.R. Detroit Community-Academic Urban
Research Center. Closed-ended survey questionnaire for board evaluation, 1997-2002. In Methods in Community-
Based Participatory Research for Health Israel, B.A., Eng E., Schulz, A.J., Parker, E.A., eds. John Wiley & Sons,
San Francisco, CA, 430-433, 2005.

Spanish version
ESTRATEGIAS RELACIONADAS A LA MISIÓN Y PLANES DE ACCIÓN
siguiente:
Firmemente En De Firmemente No sabe/
en desacuerdo acuerdo de acuerdo No sé
desacuerdo
e) Nuestra coalición comprende y comparte

claramente los problemas que estamos 1 2 3 4 5
tratando de trabajar
f) Existe un acuerdo general con relación a

1 2 3 4 5
la misión de la coalición
g) Existe un acuerdo general con relación a

1 2 3 4 5
las prioridades de la coalición
h) Los miembros de la coalición están de

acuerdo con las estrategias a utilizarse 1 2 3 4 5
para alcanzar sus prioridades
e) Nuestro plan de acción define bien los
roles, las responsabilidades y el
calendario de trabajo para llevar a cabo 1 2 3 4 5
las actividades dirigidas a alcanzar la
misión establecida por la coalición
siguiente:
desacuerdo acuerdo
d) Las reuniones se notifican a tiempo 1 2 3 4 5
e) El material para las reuniones se prepara y

distribuye a tiempo y con anticipación 1 2 3 4 5
(agendas, minutas, documentos de estudio)
f) Los informes que los comités y/o los “task

forces” preparan se distribuyen regularmente 1 2 3 4 5
a toda la coalición

Spanish version
PARTICIPACIÓN
Q24. Durante el último año, ¿cuán involucrado ha estado Ud. en las actividades de la coalición?
1. Para nada estuve involucrado

2. Un poco involucrado
3. Bastante involucrado
4. Muy involucrado
Q25. Por favor circule el número que indique cuantas veces durante el último año Ud. ha hecho
personalmente una de las siguientes para la coalición:
Nunca Raramente Algunas Frecuentemente No
(1-2 veces) veces (más de 5 veces) Aplica
(3-4 veces )
f) Reclutar nuevos miembros 1 2 3 4 5
g) Servir como portavoz 1 2 3 4 5
h) Tratar de conseguir apoyo externo para 1 2 3 4 5

posiciones de la coalición sobre asuntos
claves
i) Trabajar en la implementación de actividades 1 2 3 4 5

o eventos patrocinados por la coalición
(fuera de reuniones de la coalición)
j) Adquirir fondos u otros recursos para la 1 2 3 4 5

coalición
siguiente:
desacuerdo acuerdo
e) Siento que tengo voz en lo que la coalición 1 2 3 4 5

decide
f) Participo en las reuniones de la coalición solo 1 2 3 4 5

porque es parte de mi trabajo
g) Estoy satisfecho/a de cómo funciona la 1 2 3 4 5

coalición
h) Tengo un gran sentido de “lealtad” hacia la 1 2 3 4 5

coalición

Spanish version
siguiente. Si Ud. se considera un miembro individual (si circuló el #1 en la Q2), por favor no
conteste esta pregunta y pase a la pregunta Q28.

desacuerdo acuerdo
f) El personal de mi organización contribuye con 1 2 3 4 5

su tiempo a la coalición
g) Voluntarios de mi organización contribuyen con 1 2 3 4 5

su tiempo a la coalición
h) Mi organización apoya las posiciones de la 1 2 3 4 5

coalición públicamente
i) En general mi organización está comprometida 1 2 3 4 5

con la labor de la coalición
j) Mi organización contribuye con fondos para 1 2 3 4 5

apoyar la coalición

Spanish version
Q28. Por favor circule el número que indique hasta que punto cada uno de los siguientes ha sido
un beneficio por su participación o la de su organización en la coalición:
Ningún De Poco Algún De gran No

Beneficio Beneficio Beneficio Beneficio Aplica
l) Desarrollando relaciones colaborativas con otras 1 2 3 4 5

agencias
m) Ayudando a mi organización a acercarse a sus 1 2 3 4 5

metas
n) Consiguiendo acceso a poblaciones seleccionadas 1 2 3 4 5

con las que antes teníamos poco contacto
o) Consiguiendo fondos para mi organización 1 2 3 4 5
p) Consiguiendo servicios para nuestros clientes 1 2 3 4 5
q) Consiguiendo referidos para nuestra clientela a 1 2 3 4 5

través de otras fuentes
r) Aumentando mis habilidades profesionales y 1 2 3 4 5

conocimiento
s) Manteniéndome bien informado en un ambiente de 1 2 3 4 5

cambios constantes
t) Consiguiendo acceso a personas que toman 1 2 3 4 5

decisiones políticas claves
u) Aumentando el sentido de que otros comparten mis 1 2 3 4 5

metas y preocupaciones
v) Consiguiendo apoyo para asuntos sobre las
políticas que nuestra organización apoya 1 2 3 4 5
firmemente

Spanish version
Q29. Por favor circule el número que indique hasta que punto cada uno de los siguientes han
sido problema en su participación o en la participación de su organización en la coalición.
No es un Un Un No Aplica
problema problema problema
menor mayor
k) Las actividades de la coalición no alcanzan los grupos que 1 2 3 4

constituyen nuestro público primario
l) El trabajo de mi organización no obtiene suficiente 1 2 3 4

reconocimiento público en la coalición
m) Estar involucrado en abogar por políticas de apoyo es 1 2 3 4

problemático
n) Mis habilidades y tiempo no son bien utilizados 1 2 3 4
o) Mi opinión (o la de mi organización) no es valorada 1 2 3 4
p) La coalición no está tomando ninguna acción significativa 1 2 3 4
q) Con frecuencia soy la única voz que representa mi punto de vista 1 2 3 4

r) La carga financiera de viajar a las reuniones de la coalición es
muy alta 1 2 3 4
s) La carga financiera de participar en actividades de la coalición
(excepto gastos de viaje) es muy alta 1 2 3 4
t) La coalición compite con mi organización 1 2 3 4
Q30. Desde el punto de vista de su organización (si aplica), ¿los beneficios de participar en la
coalición en este momento sobrepasan los costos (por ejemplo, esfuerzo y tiempo
invertido)?
1. No
2. Sí
3. No represento ninguna organización en la coalición
Q31. Desde el punto de vista personal y/o profesional, ¿los beneficios de participar en la
coalición en este momento sobrepasan los costos (por ejemplo, esfuerzo y tiempo
invertido)?
1. No
2. Sí
3. No sabe/No sé

Spanish version
COMUNICACIÓN
lo siguiente.
Firme-
Firmemente en En De No sabe/
mente de
desacuerdo desacuerdo acuerdo No sé
acuerdo
a) El método actual de comunicación entre
los miembros y líderes/personal de la 1 ó 3 4 5
coalición es efectivo
b) Los miembros de la coalición pueden
comunicarse entre ellos/as cuando lo 1 2 3 4 5
necesiten o deseen
c) El personal de la coalición facilita la
comunicación entre los miembros de la 1 2 3 4 5
coalición
d) El personal de la coalición me notifica
efectiva y eficientemente sobre reuniones, 1 2 3 4 5
asuntos, agendas, etc.
CONOCIMIENTO SOBRE EL ASMA
Q33. ¿Cree Ud. que tiene un conocimiento adecuado sobre el asma pediátrica para funcionar
efectivamente en la coalición?
1. No
2. Sí
Q34. ¿Le ha ayudado la coalición a aprender más sobre el asma pediátrica?
1. No
2. Sí
MADUREZ DE LA COALICIÓN, PREPARACIÓN, SOSTENIMIENTO
Q35. ¿Ha sido su coalición responsable de actividades o programas que de otra forma no
hubieran ocurrido?
1. No
2. Sí
3. No sabe/No sé

Spanish version
Q36. ¿Ha traído su coalición beneficio a su comunidad?
1. No
2. Sí
3. No sabe/No sé
lo siguiente:

desacuerdo acuerdo
c) La coalición está progresando en la 1 2 3 4 5

implementación de actividades que tienen el
potencial de mejorar el asma pediátrica
d) La coalición está mejorando el estado de salud 1 2 3 4 5

de los niños/as con asma
lo siguiente:

desacuerdo acuerdo
a) La coalición está haciendo planes para 1 2 3 4 5

continuar operando, aún después que sus fondos
actuales se hayan terminado
b) La coalición empezó a conseguir fondos para 1 2 3 4 5

continuar operando después que los fondos
actuales se agoten
c) Se están identificando los recursos para apoyar
los cambios programáticos y de sistema 1 2 3 4 5
implementados durante el curso de trabajo de
la coalición
d) La coalición continuará existiendo aún cuando 1 2 3 4 5

los fondos de donación de la Fundación Robert
Wood Johnson se terminen

Spanish version
lo siguiente:

desacuerdo acuerdo
a) La coalición es esencial para la mejoría del

1 2 3 4 5
asma pediátrica
b) Un individuo o un grupo pequeño de

individuos o agencias podrían hacer
1 2 3 4 5
progreso significativo en la lucha contra el
asma pediátrica sin la coalición
c) En general estoy satisfecho con la
1 2 3 4 5
coalición
Q40. ¿A qué asuntos le deberían prestar mayor atención los directores/líderes de la coalición y
su personal?
Q41. ¿Ha habido algún evento crítico en el año pasado que haya tenido algún impacto en la
coalición? Por favor descríbalo.

Spanish version
Sección de Datos Demográficos de los Encuestados/as
D1. Sexo:
1. Mujer
2. Hombre
D2. Su etnicidad o raza (Circule todos los que apliquen):
1. Africano Americano/Negro
2. Blanco
3. Asiático Americano
4. Nativo de Hawaii u otras Islas del Pacífico
5. Indio Americano
6. Latino o Hispano
Si su respuesta es Latino o Hispano, usted se considera:
6a. Puertorriqueño/“Newyorrican”
6b. Mejicano/Mejicanoamericano/Chicano/a
6c. Cubano/Cubanoamericano/a
6d. Dominicano/a
6e. Otro/a caribeño/a hispano/a
6f. Sur americano/a
6g. Otro latino/Hispano/a
7. Otra raza o etnicidad (por favor especifique):_______________________
D3. Edad en su último cumpleaños:
______ Años
D4. Su educación:
1. 6to grado o menos

2. 7mo u 8vo grado
3. Algo de escuela superior/“high school”
4. Graduado/a de escuela superior
5. Graduado/a de escuela técnica o vocacional
6. Algo de universidad
7. Graduado/a de universidad
8. Algo de escuela graduada
9. Completó escuela graduada
D5. ¿Completó usted este cuestionario cuando fue administrado el año pasado?
1. No
2. Sí
3. No sabe

Spanish version
KEY INFORMANT INTERVIEW GUIDES
Description
The Key Informant Interview Guides can be used to collect a broad range of perspectives on the
activities of a coalition. The semi-structured interviews were designed to collect information from
the point of view of participants in their own words about the coalition planning process, level of
their involvement in the coalition, goals and interventions, and perceptions of coalition impact.
The follow-up interviews also address change in coalition structure and membership,
implementation of interventions, and progress toward goals, including the individual’s satisfaction
with the interventions implemented and perceptions of collaborations and linkages among
community-based organizations. Both the baseline and follow-up interviews address participants’
expectations about future outcomes and their perspectives on the value of the coalition.
Five Interview Guides are included in this document:

1. Baseline for coalition leaders or staff pgs. 2-5
2. Baseline for coalition members pgs. 6-9
3. Baseline for other community leaders pgs. 10-11
4. Follow-up for coalition leaders, staff or members pgs. 12-15
5. Follow-up for other community leaders pgs. 16-17

Developed by Allies Against Asthma and the Battelle Centers for Public Health Research and
Evaluation, 2003.
For use and/or adaptations of this document, please credit Allies Against Asthma and the Battelle
Centers for Public Health Research and Evaluation.
Contact Information
Allies Against Asthma National Program Office Phone: 734-615-3312
Center for Managing Chronic Disease Fax: 734-763-7379
University of Michigan E-mail: asthma@umich.edu
109 South Observatory Street www.AlliesAgainstAsthma.net
This is a product of Allies Against Asthma, a national project supported by The Robert Wood Johnson Foundation. Direction and
technical assistance is provided by the National Program Office at the University of Michigan Center for Managing Chronic Disease.
Allies Against Asthma Key Informant Interview Guide
Baseline for Coalition Leaders or Staff
A. BACKGROUND
First I’d like to learn about your role in local AAA name and how you became involved.
1. When did you first get involved with local AAA name? ________ mo/yr
How did you find out about the coalition?
(probe for past involvement with asthma issues)
2. How would you describe your involvement in the coalition? Probe for specific
committees and intervention activities.
Probes: Why did you choose to get involved with the coalition? How has your
role changed over the life of the coalition? What changes do you
anticipate in the future? What motivates you personally to participate?
If person is a coalition staff member, What was your previous job?
If person represents an organization, What is your position? How did the
organization become involved? What was the organization’s
involvement in asthma prior to joining the coalition?
3. What previous activities in this community, if any, did local AAA name build on?
(probe for earlier coalitions and activities either directly or indirectly related to
asthma)
B. PLANNING PROCESS
Next, I’d like to discuss the process that local AAA name used to develop its goals and
interventions.
1. What strategies did the coalition use to bring relevant players to the table?
Probes: Has this changed over time?

Are all important sectors represented?
If no, What barriers exist to participation by those sectors?
If yes, What factors facilitate their participation?
Are there specific groups or organizations that are participating in the
coalition that were not part of previous asthma control efforts in this
community?
If yes, What do you think has facilitated their involvement?
What impact has their participation had on the decisions the coalition
has made? On the activities of your subcommittee?
Allies Against Asthma 5 Key Informant Interview Guides

Baseline for Coalition Leaders or Staff 2 of 17
2. How responsive do you feel that the coalition has been to your needs? To the needs
of the other participants?
3. What have been the major challenges faced by the coalition so far? How did you
overcome them?
4. What have been the major strengths of the coalition to date? How does the coalition
build on these?
C. GOALS AND INTERVENTIONS
Now I’d like to talk about the goals that local AAA name set through the planning
process and the interventions that you are beginning to implement.
1. How realistic do you think the goals are?

Are they attainable? Are they ambitious enough?
2. How satisfied are you overall with the interventions the coalition has planned?
Do they target what is important? Do they reflect the needs of the community?
(probe for creativity and out-of-the-box thinking)
3. Thinking about the specific interventions, which ones could have been conceived
and implemented by one of the member organizations acting alone?
Probes: Which interventions could only have been generated through collective
thinking and action? (ask for specific examples using matrix if needed)
To what extent do they require multiple organizations and/or groups to
work together to be successful?
Did these groups work together before this coalition was formed?
In what ways has the coalition supported and encouraged these partners to
work together? (probe for issues of trust, conflict, leadership)
D. IMPACTS
Next, I’d like to talk about what impacts the coalition is having on you personally, the
organizations you are associated with, and the community at large.
1. How has being involved with this coalition been of benefit to you? Has
participation changed the way you personally think about or approach asthma? Have
these changes in your thinking translated into specific actions already? (If yes, probe
for examples). How might they in the future?

2. (Note: ask only if individual is a representative of an organization)
How has being involved with this coalition been of benefit to your organization?
Has participation changed the way your organization approaches asthma?
Probes: Has the presence of the coalition in the community had any effect on
a) the level of exchange of resources and information among
organizations? (probe for formal agreements/structures)
b) the ability of member organizations to secure additional resources
for asthma control? (probe for new funding, in-kind services)
c) the ability of member organizations to pursue related goals, such as
other pediatric health issues, or asthma control among other
populations? (probe for examples of applying new knowledge, skills,
connections)
3. To what degree does the coalition collaborate with other organizations or

individuals outside the coalition that are involved in asthma control?
How, or why not?
(probe for new organizations and new sectors being involved)
4. How visible is the coalition in this community? (probe for media coverage,
visibility within top levels of key organizations, public awareness)
5. Has the coalition had an effect on support for pediatric asthma prevention and
control programs in this community? (probe for legislative/governmental
involvement, increase in community involvement, nonmembers expressing interest
in the coalition activities/results, dissemination of results within community, new
policies, changes in clinical care systems, new systems introduced into the
community)
6. Are there any other benefits or impacts of the coalition that you have observed at this
point in time? (probe for application of knowledge/skills beyond those directly
funded)
7. Thinking about all of the impacts we just discussed, which of these do you think
might have happened even without the coalition?

E. FUTURE IMPACTS
Next, I’d like to talk a little bit about what lies ahead for the coalition.
1. What are the main interventions that will be going on in the next two years?
Probes: What organizations are involved? What will your role be?
What results do you expect from those interventions?
2. What, if any, major challenges do you anticipate in the future as the coalition
implements this plan?
3. What would you like to see occur for you to feel that local AAA name has been a
success?
F. NPO
Last, I’d like to ask you a couple of questions about the National Program Office of
Allies Against Asthma.
1. Are you familiar with the NPO? (If not, explain that the Univ. of Michigan
serves as a coordinating center for the 7 community coalitions funded under AAA)
If yes, What interaction have you had with the NPO?

How do you view the role and function of the NPO?

Baseline for Coalition Members
A. BACKGROUND
First I’d like to learn about your role in local AAA name and how you became involved.
1. When did you first get involved with local AAA name? ________ mo/yr
How did you find out about the coalition?
(probe for past involvement with asthma issues)
2. How would you describe your involvement in the coalition?

(probe for specific committees and intervention activities)
Probe: Why did you choose to get involved with the coalition? How has your
role changed over the life of the coalition? What changes do you
anticipate in the future? What motivates you personally to participate?
If person represents an organization, What is your position? How did the
organization become involved? What was the organization’s
involvement in asthma prior to joining the coalition?
3. What previous activities in this community, if any, did local AAA name build on?
(probe for earlier coalitions and activities either directly or indirectly related to
asthma)
B. PLANNING PROCESS
Next, I’d like to discuss the process that local AAA name used to develop its goals and
interventions.
1. What strategies did the coalition use to bring relevant players to the table?
Probes: Has this changed over time?

Are all important sectors represented?
If no, What barriers exist to participation by those sectors?
If yes, What factors facilitate their participation?
Are there specific groups or organizations that are participating in the
coalition that were not part of previous asthma control efforts in this
community?
If yes, What do you think has facilitated their involvement?
What impact has their participation had on the decisions the coalition
has made?
2. During the planning phase, how responsive do you feel that the coalition has been to
your needs? To the needs of the other participants?

Baseline for Coalition Members 6 of 17
3. What have been the major challenges faced by the coalition so far? How did the
coalition overcome them?
4. What have been the major strengths of the coalition to date? How does the coalition
build on these?
Now I’d like to talk about the goals that local AAA name set through the planning
process and the interventions that you are beginning to implement.
1. How realistic do you think the goals are?

Are they attainable? Are they ambitious enough?
2. How satisfied are you overall with the interventions the coalition has planned?
Do they target what is important? Do they reflect the needs of the community?
(probe for creativity and out-of-the-box thinking)
3. Thinking about the specific interventions, which ones could have been conceived
and implemented by one of the member organizations acting alone?
Probes: Which could only have been generated through collective thinking and
action? (ask for specific examples using matrix if needed)
To what extent do they require multiple organizations and/or groups to
work together to be successful?
Did these groups work together before this coalition was formed?
In what ways has the coalition supported and encouraged these partners to
work together? (probe for issues of trust, conflict, leadership)
D. IMPACTS
1. How has being involved with this coalition been of benefit to you? Has
participation changed the way you personally think about or approach asthma? Have
these changes in your thinking translated into specific actions already? (If yes, probe
for examples). How might they in the future?

2. (Note: ask only if individual is a representative of an organization)
How has being involved with this coalition been of benefit to your organization?
Has participation changed the way your organization approaches asthma?
for asthma control? (probe for new funding, lobbying, in-kind services)
c) the ability of member organizations to pursue related goals, such as
connections)

How, or why not?
(probe for new organizations and new sectors being involved)
4. How visible is the coalition in this community? (probe for media coverage,
5. Has the coalition had an effect on support for pediatric asthma prevention and
control programs in this community? (probe for legislative/governmental
involvement, increase in community involvement, nonmembers expressing interest
in the coalition activities/results, dissemination of results within community, new
policies, changes in clinical care systems, new systems introduced into the
community)
funded)

E. FUTURE IMPACTS
Next, I’d like to talk a little bit about what lies ahead for the coalition.
1. What are the main interventions that will be going on in the next two years?
Probes: What organizations are involved? What will your role be?
What results do you expect from those interventions?
2. What, if any, major challenges do you anticipate in the future as the coalition
implements this plan?
success?
F. NPO
Last, I’d like to ask you a couple of questions about the National Program Office of
Allies Against Asthma.
1. Are you familiar with the NPO? (If not, explain that the Univ. of Michigan
serves as a coordinating center for the 7 community coalitions funded under AAA)
If yes, What interaction have you had with the NPO?

How do you view the role and function of the NPO?

Baseline for Other Community Leaders
(For people who are in leadership positions in the community in organizations whose
mission overlaps with that of the coalition, and that may send representatives to the
coalition but are not themselves involved in any intimate fashion)
A. BACKGROUND
I’d like to begin by having you tell me a little bit about yourself and what you do that
brings you in contact with asthma control issues in your community.
1. What are your major job-related activities and responsibilities? (probe for how
these relate to asthma control issues)
2. How did you first learn about local AAA name? When was this?
3. What specific activities, if any, bring you in contact with local AAA name?
4. Do you or your organization currently provide any support to the coalition? Why or
why not?
I’d like to hear your perspective on local AAA name.
1. How do you see the role of local AAA name in the community?
2. Do you think local AAA name meets an important need? Please explain (probe
for their perspective on what the needs are and which of these the coalition could
or could not appropriately address)
D. IMPACTS
1. What benefits, if any, have you or your organization experienced from the presence
of local AAA name in the community?
2. How visible is local AAA name in this community? (probe for media coverage,

Baseline for Other Community Leaders 10 of 17
3. How, if at all, has local AAA name affected support for pediatric asthma
prevention and control programs in this community?
4. What, if any, other benefits or impacts of local AAA name have you observed at this
point in time?
E. FUTURE IMPACTS
Last, I’d like to talk a little bit about what lies ahead.
1. What interaction do you or your organization expect to have with local AAA
name over the next two years? (probe for support they might provide)
success in this community?

Baseline for Other Community Leaders 11 of 17
Follow-up for Coalition Leaders, Staff or Members
A. BACKGROUND
First I’d like to learn about how your role in local AAA name may have changed since we
last spoke.
1. What have been your primary responsibilities or activities in the past year? How
does this differ from your earlier role?
B. STRUCTURE AND MEMBERSHIP
Next, I’d like to discuss how the membership of local AAA name may have changed in
the past year and any significant changes you perceive in how the coalition operates.
1. How, if at all, has the membership in the coalition changed in the past year?
Probes: Who (sectors) is active that wasn’t before? Are they new to asthma
control?
Have any members dropped out? Why do you think they have left?
Are all important sectors currently represented?
2. What changes have there been in work group structure, decision-making procedures,
meeting schedules, or other operations of the coalition?
Probes: Why have these changes occurred? What effect do you think these
changes have had on the activities or effectiveness of the coalition?
[If staff or PI, probe for changes in staffing or lead agency]
3. What have been the major challenges faced by the coalition in the past year? How
does the coalition overcome them?
4. What have been the major strengths of the coalition in the past year? How does the
coalition build on these?

Follow-up for Coalition Leaders, Staff or Members 12 of 17
Before we move on to talking about the impacts of the coalition, I’d like to ask about
the status of goals or interventions that you had established when we last spoke over a
year ago.
1. Which interventions are currently active?

How are they organized? Who (ie, which workgroup/committee/organization(s))
is active in implementing each one? What results have you seen so far?
2. Are there any interventions that have become inactive in the past year? Please
describe them and explain what motivated these developments.
3. Has the coalition established any new goals or developed new interventions in the
past year? Please describe them and explain what you think motivated these
developments. What funding/resources/infrastructure do you have to begin and
maintain these interventions?
4. At this point in time, how satisfied are you overall with the interventions the
coalition is implementing? Do they target what is important? Do they reflect the
needs of the community? (probe for creativity and out-of-the-box thinking)
D. IMPACTS
organizations you are associated with, and the community at large. We asked you about
impacts last time we spoke. This time, I would like you to focus your answers on what has
occurred since we last spoke.
1. Since we last spoke, have you experienced any additional personal benefits of
participation in the coalition? How has being involved with this coalition been of
benefit to you? Has participation changed the way you personally think about or
approach asthma or your work in general? Have these changes in your thinking
translated into specific actions already? (If yes, probe for examples). How might
they in the future?
2. (Note: ask only if individual is a representative of an organization. How has

being involved with this coalition been of benefit to your organization? Since we
last spoke, have you seen changes in the way your organization approaches asthma
that may be due to being involved in the coalition?
2a. How has this coalition changed the activities and/or approaches of other
organizations or the way they interact with each other?

for asthma control? (probe for new funding, in-kind services)
c) the ability of the coalition to secure additional resources?
d) the ability of member organizations to pursue related goals, such as
connections)

How, or why not?
(probe for new organizations and new sectors being involved, increase in
community involvement, nonmembers expressing interest)
4. How visible is the coalition in this community currently? (probe for media
coverage, visibility within top levels of key organizations, public awareness,
dissemination of results)
8. Has the coalition had an effect on pediatric asthma prevention and control in this
community? We define community broadly to include homes, clinics, schools,
public policies, and interactions among these and other sectors (probe for
environmental changes in homes, changes in community settings that improve
patient self-management and family capacity building, provider training, changes
in supportive policies, legislative/governmental involvement, changes in clinical
care systems, new systems introduced into the community)
funded)
E. FUTURE IMPACTS
Last, I’d like to talk a little bit about what lies ahead for the coalition.
1. What do you hope to achieve during this remaining period of Allies funding?
2. Do you feel that local AAA name has been a success? In what way?

3. Has local AAA name fallen short of your expectations in any way? How?
4. After RWJF funding ends, what does the future look like for the coalition itself?
For the primary interventions? Will they continue and if so, how? (probe for
institutionalization through the coalition, member organization, or individual
member involvement) Why were these choices made?
5. Are there any additional comments you would like to share about being part of
this coalition?

Follow-up for Other Community Leaders
(For people who are in leadership positions in the community in organizations whose
mission overlaps with that of the coalition, and that may send representatives to the
coalition but are not themselves involved in any intimate fashion)
A. BACKGROUND
I’d like to begin by learning how your role in asthma control issues in your community
may have changed since we last spoke.
1. What are your current activities and responsibilities as they relate to asthma control?
2. What contact, if any, have you had with local AAA name since we last spoke? Do
you provide any support to the coalition?
I’d like to hear your current perspective on local AAA name.
1. How do you see the role of local AAA name in the community?
2. Do you think local AAA name meets an important need? Please explain (probe
for their perspective on what the needs are and which of these the coalition could
or could not appropriately address)
D. IMPACTS
1. What benefits, if any, have you or your organization experienced from the presence
of local AAA name in the community?
2. How visible is local AAA name in this community? (probe for media coverage,
3. How, if at all, has local AAA name affected support for pediatric asthma
prevention and control programs in this community?

Follow-up for Other Community Leaders 16 of 17
4. What, if any, other benefits or impacts of local AAA name have you observed at this
point in time?
E. FUTURE IMPACTS
Last, I’d like to talk a little bit about what lies ahead.
1. What interaction do you or your organization expect to have with local AAA
name in the next year or beyond? (probe for support they might provide during
current funding period and beyond)
success in this community? Have you witnessed any progress towards this
definition of success since we last spoke?

Follow-up for Other Community Leaders 17 of 17
PROGRAM REACH FORMS
Description
Included in this document is a selection of forms that can be used to track coalition
activities. The forms were developed by Allies Against Asthma for Program Reach, a web-
based database used to capture data on the extent of coalition activities. Program Reach is a
password-protected, site-specific tracking system used by coalition staff to enter data that
describes the coalition activities conducted including the number and type of program
participants, topics addressed and settings in which activities were conducted.

Developed by Allies Against Asthma, 2003. The concept for Program Reach was based upon
the Central California Asthma Project (CCAP) Activities Database. CCAP is a project of the
San Joaquin Valley Health Consortium and the American Lung Association of Central
California, Fresno, CA, and CCAP-affiliated community asthma coalitions. The Activities
Database was developed for CCAP by the Department of Health Services Research, Palo
Alto Medical Foundation Research Institute, Palo Alto, CA, with support from the National
Heart, Lung, and Blood Institute of National Institutes of Health.
For use and/or adaptations of this document, please credit Allies Against Asthma and the
Department of Health Services Research, Palo Alto Medical Foundation Research Institute.
Contact Information
Allies Against Asthma National Program Office Phone: 734-615-3312
Center for Managing Chronic Disease Fax: 734-763-7379
University of Michigan E-mail: asthma@umich.edu
109 South Observatory Street www.AlliesAgainstAsthma.net
I. Training Individuals who Work with Children with Asthma
Curriculum/Description: (specify) Setting where Participants Work:
(check all that apply)
Clinic
Head Start
Emergency Department
Participants:(enter number of Elementary School
participants) Hospital (Non-Emergency Department)
Medical Providers Middle/Junior High
Physicians Private Medical Practice
Nurses High School
Other Allied Health Day Care
Professionals After-School/Parks & Rec.
Medical Office Staff Preschool
Other (specify): Health Education Center
Community Based Organization
Other (specify):
School-Based/Day Care/HeadStart
Personnel
Topics Addressed: (check all that apply)
Administrators
Asthma Basics
Engineers/Custodians
Recognition of Asthma Emergency
Physical Education
Case Finding
Staff/Coaches
Self Management Skills
School Nurses
Medical Therapies
Teachers
Communication Skills
Day Care/HeadStart Workers
Improving Environmental Conditions
Other (specify):
Tobacco Cessation
Policies and Procedures
Interviewing Skills
Other (specify):
Others Who Work with Children with
Asthma
Community Health Workers
Health Educators Curriculum/Program Period
Social Workers Term of Activity (check one)
Community Agency Staff ° Time Limited Activity On-Going Activity
Community Volunteer
WIC Staff Reporting Period/Date of Activity
After-School/Parks and Start Date
Recreation Staff (mm/dd/yyyy): ______________
Other (specify): End Date
(mm/dd/yyyy): ______________
Number of Comments:
training sessions:
Number of total
educational hours:
_____________________________________________________________________________________________________________________
Allies Against Asthma 5 Program Reach Forms 2 of 8
II. Care Coordination
Coordination Provided By: (Check all that apply) Number of Children:

Community Health Worker/Outreach Worker Number of Children Served ______
Nurse/Public Health Nurse Number of Total Contacts ______
Social Worker Number of First Contacts ______
Health Educator
Other (specify):
Reporting Period:
Start Date (mm/dd/yyyy) _______
End Date (mm/dd/yyyy) _______
Coordination Provided Type: (Check all that apply)

Clinical Care Comments:
Asthma-related Educational Programs
Home-based Support
School-based Support
Social Services
Tobacco Cessation Education/Support
Advocacy
Assistance Obtaining Medications/Equipment
Assistance Enrolling / Maintaining Insurance
Other (specify):
_____________________________________________________________________________________________________________________
III. Home Visiting
Visits Conducted By: (Check all that apply) Age of Target Population:
Community Health Worker/Outreach (Check all that apply)
Worker 0 - 5 year olds
Nurse Public Health Nurse Elementary School
Social Worker Middle/Junior High
Health Educator High School
Other (specify): Above High School
Visits Conducted:
Number of Homes Visited _______
Number of Children Visited _______
Number of Total Visits _______
Number of First Visits _______
Zip Codes of Homes Visited:
Program Focus: (Check all that apply)
Education
For Example:
Asthma Basics
Self-management Skills Reporting Period:
Environmental Triggers Start Date (mm/dd/yyyy)
Advocacy Skills End Date (mm/dd/yyyy)
Environmental Action
For Example:
Environmental Assessment
Comments:
Smoking Cessation
Distribution of Trigger Reduction
Materials
Case Management
For Example:
Referrals
Other Social Issues
Other (specify):
_____________________________________________________________________________________________________________________
IV. Educating Children with Asthma and/or Their
Parents/Caregivers Outside of Their Home
Curriculum: Participants:
Title or Description: (specify) Group or Individual:
° Group °Individual
Number of Sessions
Children with Asthma
Topics Addressed: (Check all that
Number of Children ________
apply)
Number of New Children ________
Asthma Basics
Number of Total Educational Hours_______
Self Management Skills
Parents/Caregivers
Medications and Equipment
Number of Parents/Caregivers ________
Environmental Triggers
Number of New Parents/Caregivers _______
Advocacy Skills
Number of Total Educational Hours_______
Peer Support
Other (specify):
Period and Location of Activity:
Term of Activity: (check one)
° Time Limited Activity °On-Going Activity
Setting: (check all that apply) Reporting Period:
Day Care Start Date (mm/dd/yyyy) __________
Pre School End Date (mm/dd/yyyy) __________
Head Start/Early Head Start Zip Codes:
Elementary School
Middle/Junior High
High School
After-school/Parks and Recreation
Clinic Comments:
Emergency Department
Hospital (Non-ED)
Asthma Camp
Community
Other (specify):
Educators: (Check all that apply)

Community Health Worker
Health Educator
Health Care Provider (Ex: Nurse)
Social Worker
Teacher
Community Volunteer
Other (specify):
_____________________________________________________________________________________________________________________
V. Actions to Improve Physical Environmental Conditions within
Institutions
Setting: (choose one) Date and Location of Activity:

° Day Care Reporting Period:
Start Date (mm/dd/yyyy) ________
° Preschool (Non-Head Start) End Date (mm/dd/yyyy) ________
° Head Start/Early Head Start
Zip Codes:
° Elementary School
° Middle/Junior High
° High School Comments:
° After-School/Parks and Recreation

° Housing
° Community
° Other (specify):
Topics: (check all that apply)

Environmental Assessment
Mold/Spore Reduction
Pest Management
Dust/Air Allergen Reduction
Other (specify):
_____________________________________________________________________________________________________________________
VI. Quality Improvement
Systems Involved (provide numbers)
____ In-Patient Hospital Breadth of Activity (optional)
____ Number of Charts Audited/Abstracted
____ Emergency Department ____ Number of Incentives Provided
____ Number of Participants Provided Feedback on
____ Primary Care Physicians Performance
____ Other (specify):
____ Specialists
____ Clinic
____ MCO/Insurer Reporting Period

Start Date (mm/dd/yyyy) _______
____ School End Date (mm/dd/yyyy) _______
____ Daycare/Preschool/Headstart
Describe/Comments:
____ Home Visiting Program
____ Community Based

Organization
____ After-school/Parks and

Recreation
Target Population/Participants:
(provide numbers for all that apply)
____ Physicians
____ Nurses
____ Educators
____ Clerks/Administrative
Personnel
_____________________________________________________________________________________________________________________
VII. General Community Awareness Activities
Activities: (complete all that apply) Reporting Period:

Start Date (mm/dd/yyyy): _________
Community Events (enter number of activities) End Date (mm/dd/yyyy): _________
_____ Health Fairs
_____ Community Forum

Comments:
_____ Fundraisers
_____ Approximate Total Number of

Participants
Presentations (enter number of activities)

_____ General Asthma Presentations
_____ Presentations about the Coalition
_____ Approximate Total Number of

Participants
Media Campaigns (enter number of activities)

_____ Number of Newspaper/Magazine
Stories
_____ Number of TV/Radio Stories
_____ Number of Billboard, Bus or Posters

Mounted
Other Community Events (enter number of

activities)
_____ Theater Production
_____ Other (specify):
Environmental Actions (Describe:)
_____________________________________________________________________________________________________________________
ASTHMA CORE CAREGIVER SURVEY
Instrument Description
The Asthma Core Caregiver Survey can be used to assess individual-level asthma-
related outcomes. This instrument is a compilation of previously existing surveys
designed to collect self-report data about asthma management, exposures to
community events and programs, and outcomes. It was designed to measure
individual outcomes between baseline and follow-up periods within an intervention
and control/comparison group. It measures the following:
• Quality of Life: The Paediatric Asthma Quality of Life Questionnaire was used to
measure quality of life. (To obtain this questionnaire and additional information
about its use, please go to http://www.qoltech.co.uk/PaedAsthma.htm )
• Asthma Symptoms
• Exposure to Asthma-Related Community Events and Programs
• Parent Asthma Management Strategies
• Hospitalizations and Emergency Department visits (self-report)
The English version and a Spanish translation are included in this document.

Adapted by Allies Against Asthma, 2003.
For use and/or adaptations of this document, please credit Allies Against Asthma
and the applicable references below.
REFERENCES
Quality of Life
Juniper, E. F., Guyatt, G. H., Feeny, D. H., Ferrie, P. J., Griffith, L. E., & Townsend,
M. (1996). Measuring quality of life in the parents of children with asthma. Quality of
Life Research, 5, 27-34.
Asthma Symptoms
Evans, R. 3rd., Gergen, P.J., Mitchell, H., Kattan, M., Kercsmar, C., Crain, E.,
Anderson, J., Eggleston, P., Malveaux, F.J., Wedner H.J., (1999). A randomized
clinical trial to reduce asthma morbidity among inner-city children: Results of the
National Cooperative Inner-City Asthma Study. Journal of Pediatrics, 135(3):332-8
Exposure to Community Events and Programs

Fisher, E. B., Strunk, R. C., Sussman, L. K., Sykes, R. K., & Walker, M. S., (2004).
Community organization to reduce the need for acute care for asthma among African
American children in low-income neighborhoods: The Neighborhood Asthma
Coalition. Pediatrics, 114, 116-123.
Fisher, E. B., Sussman, L. K., Arfken, C., Harrison, D., Munro, J., Sykes, R. K., Sylvia,
S. & Strunk, R. C., (1994). Targeting high risk groups: Neighborhood organization
for pediatric asthma management in the Neighborhood Asthma Coalition. Chest, 106,
248S-259S.
Fisher, E. B., Strunk, R. C., Sussman, L. K., Arfken, C., Sykes, R. K., Munro, J. F.,
Haywood, S., Harrison, D., & Bascom, S., (1996). Acceptability and feasibility of a
community approach to asthma management: The Neighborhood Asthma Coalition
(NAC). Journal of Asthma, 33, 367-383.
Parent Asthma Management Strategies

Clark, N. M., Feldman, C. H., Evans, D., Duzey, O., Levison, M. J., Wasilewski, Y.,
Kaplan, D., Rips, J., Mellins, R.B., (1986). Managing better: children, parents, and
asthma. Patient Education and Counseling, 8, 27-38.
Contact Information
Phone: 734-615-3312
Fax: 734-763-7379
ASTHMA CORE CAREGIVER SURVEY
Date of administration: _____/______/_______
Site ID# _______

Respondent ID# ________
Administration Method:
(check one)
____ Self-administered
____ Interviewer-administered
If interviewer-administered:
Interviewer ID: _______
How interviewed? _____phone ______face-to-face
Language:
____ English
____ Spanish
____ Other _____________________
___________________________________________________________________________________
Allies Against Asthma 5 Asthma Core Caregiver Survey 3 of 22
English version
Paediatric Asthma Caregiver’s Quality of Life Questionnaire
This section, two pages long, is not included in this document due to
copyright restrictions; to obtain this questionnaire and additional
information about its use, please go to
http://www.qoltech.co.uk/PaedAsthma.htm
___________________________________________________________________________________
English version
Asthma Symptoms
These next four questions ask about how asthma affects you and [CHILD] each
day. The questions ask about asthma symptoms during two different time periods:
in the last 14 days, and over the last 12 months.
S1. During the daytime in the last 14 days, how many days did [CHILD] have
asthma symptoms such as wheezing, shortness of breath, tightness in the chest, or
cough? ____Days
S1.1 How about in the last 12 months? ____Days
Begin with a PAUSE, if no answer restate the question.

Avoid ranges: if given a range, i.e. 2 to 5 days a month, ask, “would that
be closer to 2 or closer to 5? Is that every month?
If respondent says it varies during the year ask “at the worst time how
many days a month? For how many months? And the rest of the year,
how many days a month?
If respondent says most of the time, or all of the time etc. restate the
response “do you mean a few days a week? How many?” “Do you mean
every day of the year?”
INTERVIEWER: Calculate and enter responses adjusted for 12 months.
S2. During the nighttime in the last 14 nights, how many nights did [CHILD]
wake up because of asthma symptoms such as wheezing, shortness of breath,
tightness in the chest, or cough?
____Nights
S2.1 How about in the last 12 months? ____Nights
Use same probes as above replacing term “days” with “nights.”
These next two questions ask about hospitalizations and emergency visits over the
past 12 months.
S3. During the past 12 months (that is since _______), did [child] have to stay
overnight in the hospital because of asthma?
S4. Not counting hospitalizations, during the past 12 months, (that is, since
_______), did [child] go to an emergency room because of asthma?
___________________________________________________________________________________
English version
Items on Exposure to Community Events and Programs Related to
Asthma
Next are some questions about your community.
E1. Have you heard of (insert coalition name, program or other organization as appropriate)?
YES
NO
DON’T KNOW
If NO or DON’T KNOW: Go to #3
If YES, ask:
E2. How many times have you participated in activities or received help from (insert coalition
name, program or other organization as appropriate)?
**Probe if per week, month, year**

1- /week
2- /month
3- /year
NEVER
DON’T KNOW
E3. How often do you hear someone in your neighborhood talking about asthma?
VERY OFTEN
SOMETIMES
SELDOM
NEVER
DON'T KNOW
E4. Have you or your child talked with a doctor or nurse about your child’s asthma in the
last 6 months?
YES
NO
DON’T KNOW
E5. Has anyone visited your home to talk with you about your child’s asthma in the last
6 months?
YES
NO
DON’T KNOW
E6. Has anyone called you on the phone to talk with you about your child’s asthma in the
last 6 months?
YES
NO
DON’T KNOW
___________________________________________________________________________________
English version
E7. Have you or your child attended a class on asthma in your child's school in the last
6 months?
YES
NO
DON'T KNOW
E8. Have you or your child attended a class on asthma at any other place,
like a health clinic, neighborhood center, or church in the last 6 months?
YES
NO
DON'T KNOW
E9. Have you or your child participated in some other activity for people with
asthma such as a health fair, asthma camp, or neighborhood event in the last 6
months?
YES
NO
DON'T KNOW
E10. Have you heard a presentation on asthma in a church or some other community
organization in the last 6 months?
YES
NO
DON'T KNOW
E11. Have you received hand-outs or fliers or manuals on asthma in the last 6 months?
YES
NO
DON'T KNOW
E12. Have you noticed posters or billboards or other announcements in your neighborhood
about asthma in the last 6 months?
YES
NO
DON'T KNOW
E13. (Optional) Have you been to an asthma support group in the last 6 months?
YES
NO
DON’T KNOW
___________________________________________________________________________________
English version
Parent Asthma Management Strategies (long version)
Now I am going to ask some questions about things YOU may have done to manage [child’s] asthma at
home during the past 12 months. Some parents find some of these things helpful and others feel that they
are not helpful. For the past 12 months, please tell me whether you did these things to manage [child’s]
asthma
All the time, Fairly often, Not too often or Never......
During the past 12 months....

All Fairl Not
the y too Never
time often often
a. Did you give [child] asthma prescription medicine when s/he was [4] [3] [2] [1]
having symptoms
b. Did you find ways to keep yourself and [child] calm [4] [3] [2] [1]
c. Did you have [child] rest or play quietly [4] [3] [2] [1]
d. Did you take [child] away from what caused symptoms when [4] [3] [2] [1]
possible
e. Did you observe [child] to see if symptoms got better or worse [4] [3] [2] [1]
f. Did you ask someone for advice or help [4] [3] [2] [1]
g. Did you use a peak flow meter to try to predict [child’s] asthma [4] [3] [2] [1]
attacks
h. Did you watch [child] closely when symptoms began, in order to [4] [3] [2] [1]
determine how serious they were
i. Did you watch closely after giving [child] medicine to see if it [4] [3] [2] [1]
was working to reduce or stop symptoms
j. Did you try to identify things that might be triggering [child’s] [4] [3] [2] [1]
symptoms
k. Did you look for early warning signs of an asthma attack [4] [3] [2] [1]
l. Did you decide on your own whether or not the medicine was [4] [3] [2] [1]
working or needed to be changed
___________________________________________________________________________________
English version
m. Did you use some system or method for deciding when to change [4] [3] [2] [1]
the type or dose of medicine according to the changes in [child’s]
asthma symptoms
n. Did you determine if the changes you made in [child’s] [4] [3] [2] [1]
environment, for example, bedroom furnishings, household pets,
or air quality had any effect on [child’s] symptoms
o. Did you give [child] asthma medicines before s/he came in [4] [3] [2] [1]
contact with something that might cause asthma symptoms to
begin
Parent Asthma Management Strategies (short version)

I’d like to ask you about things you may have done to manage (child’s name) at home
during the past 12 months. Some parents find these things helpful, others find they are not
helpful.
For each item, please tell me how often you did these things: all the time, fairly often, not too
often, never.
All Fairly Not Never
How often did you: the Often too
time often
1. Give (child’s name) asthma prescription medicine 4 3 2 1

when he/she was having symptoms.
2. Find ways to keep yourself and (child’s name) calm 4 3 2 1

when he/she was having symptoms.
3. Have (child’s name) rest or play quietly when 4 3 2 1

he/she was having symptoms.
4. Take (child’s name) away from what caused the 4 3 2 1

symptoms.
5. Ask someone for help or advice about managing 4 3 2 1

(child’s name)’s asthma.
___________________________________________________________________________________
English version
6. Give (child’s name) asthma medicines before 4 3 2 1
he/she had contact with something that might cause
wheezing or coughing, for example, before entering a
smoky restaurant or before he/she played sports.
* Clark, N.M., Gong, M, Kaciroti, N. A model of self-regulation for control of chronic disease. Health
Education & Behavior 28(6):769-782, 2000.
___________________________________________________________________________________
English version
Demographics
Child
D1. What is your child’s sex? ___ Male ___ Female
D2. What is your child’s age and date of birth?
___ Age (in years) Date of birth:

Month Day Year
D3. Is your child Spanish/Hispanic/Latino?

Mark (X) in the “NO” box if not Spanish/Hispanic/Latino.
___ No, not Spanish/Hispanic/Latino

___ Yes, Mexican, Mexican American, Chicano
___ Yes, Puerto Rican
___ Yes, Cuban
___ Yes, other Spanish, Hispanic, Latino
(print group)______________________
D4. What is the child’s race?

Mark (X) one or more races to indicate what race the caregiver considers him or her to
be.
___ White
___ Black or African American
___ American Indian or Alaskan Native
___ Asian Indian
___ Chinese
___ Filipino
___ Japanese
___ Korean
___ Vietnamese
___ Other Asian (print race below)
___ Native Hawaiian
___ Guamanian or Chamorro
___ Samoan
___ Other Pacific Islander (print race below)
___ Other race (print race below)
(print race) ___________________________
D5. Is your child currently covered by health insurance? ___ Yes ___ No
If yes, what insurance? _________________
___________________________________________________________________________________
English version
Is that through Medicaid or CHIP (or whatever name appropriate for site)?_____
Primary Caregiver
D6. What is your zip code of residence?____________________
D7. What is your sex? ___ Male ___ Female
D8. What is your age and date of birth?
___ Age (in years) Date of birth:

Month Day Year
D9. What is your relationship to [child]?
___ Mother ____Father ____ Grandmother ____Grandfather ____ Aunt

____Uncle
___Other: (specify)___________________
D10. Are you Spanish/Hispanic/Latino?

Mark (X) in the “NO” box if not Spanish/Hispanic/Latino.
___ No, not Spanish/Hispanic/Latino

___ Yes, Mexican, Mexican American, Chicano
___ Yes, Puerto Rican
___ Yes, Cuban
___ Yes, other Spanish, Hispanic, Latino
(print group)______________________
D11. What is your race?

Mark (X) one or more races to indicate which race the caregiver consider herself or
himself to be.
___ White
___ Black or African American
___ American Indian or Alaskan Native
___ Asian Indian
___ Chinese
___ Filipino
___ Japanese
___ Korean
___ Vietnamese
___ Other Asian (print race below)
___ Native Hawaiian
___________________________________________________________________________________
English version
___ Guamanian or Chamorro
___ Samoan
___ Other Pacific Islander (print race below)
___ Other race (print race below)
(print race) ___________________________
D12. What is the highest level of school you have COMPLETED?

Mark (X) only ONCE.
If currently enrolled, mark the previous grade or highest grade completed.
Interviewer: Do not read responses. Check appropriate box and probe if necessary.
___ No schooling completed

___ Nursery school to 4th grade
___ 5th grade or 6th grade
___ 7th grade or 8th grade
___ 9th grade
___ 10th grade
___ 11th grade
___ 12th grade—NO DIPLOMA
___ HIGH SCHOOL GRADUATE—high school
DIPLOMA or the equivalent (for example: GED)
___ Some technical/vocational school
___ Completed technical/vocational school
___ Some college credit, but less than 1 year
___ 1 or more years of college, no degree
___ Associate’s degree (for example: AA, AS)
___ Bachelor’s degree (for example: BA, AB, BS)
___ Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
___ Professional degree (for example: MD, DDS, DVM, LLB, JD)
___ Doctorate degree (for example: PhD, EdD)
___ Other (please describe, including country where education took
place)______________________________________________________________
___________________________________________________________________________________
English version
D13. What was your total family income before taxes last year? (Optional)
____________________
Or
D14. Which category best describes your total family income before taxes last year? (For
interviewer-administered: “Please stop me when I get to the category that best describes
your total income.”)
___ Less than $5000

___ $5001-$10,000
___ $10,001-$15,000
___ $15,001-$20,000
___ $20,001-$30,000
___ $30,001-$40,000
___ $40,001-$50,000
___ $50,001-$60,000
___ $60,001-$70,000
___ $70,001-$80,000
___ $80,001 and above
___________________________________________________________________________________
English version
ALIANZA CONTRA EL ASMA
ENCUESTA PARA EL ENCARGADO O
GUARDIÁN PRINCIPAL DE ASMA
Fecha de administración: _____/______/______
ID. # del Sitio: _______

ID. # del entrevistado: ________
Método de administración:
(marque uno)
____ Auto-administrado
____ Administrado por el entrevistador
Si fue administrado por el entrevistador:
ID. del entrevistador: _______
¿Cómo entrevistó? _______ Teléfono ______Cara a cara
Idioma:
____ Inglés
____ Español
____ Otro_____________________
_________________________________________________________________________________________
Spanish version
Cuestionario de la Calidad de Vida de la Persona Encargada
del Cuidado del Niño con Asma
This section, two pages long, is not included in this document due to copyright
restrictions; to obtain this questionnaire and additional information about its use,
please go to http://www.qoltech.co.uk/PaedAsthma.htm
_________________________________________________________________________________________
Spanish version
Síntomas de asma
Las siguientes cuatro preguntas son acerca de cómo es que el asma los afecta a usted y a [nombre
del niño/a] cada día. Las preguntas se refieren a los síntomas del asma durante dos períodos de
tiempo distintos: durante los últimos 14 días y durante los últimos 12 meses.
S1. Durante el día en los últimos 14 días, ¿cuántos días tuvo [nombre del niño/a] silbidos (pitos)
al respirar, falta de aire, opresión en el pecho o tos?
S1.1 ¿Y durante los últimos 12 meses? ____ Días
Empiece con una PAUSA, si no hay respuesta, repita la pregunta.

Evite períodos de tiempo: por ejemplo si le contesta de 2 a 5 días al mes, pregunte
“eso sería más cerca a 2 ó a 5? Y eso es ¿cada mes?
Si el entrevistado responde que varía durante el año pregunte, “durante la peor época
¿cuántos días al mes? ¿Cuántos meses? Y durante el resto del año ¿cuántos días al
mes?”
Si el entrevistado responde la mayor parte del tiempo o todo el tiempo, etc. repita la
respuesta diciendo “¿Usted quiere decir unos pocos días a la semana? ¿Cuántos
días?” “¿Quiere decir todos los días del año?”
ENTREVISTADOR: Calcule y escriba las respuestas ajustándolas a 12 meses.
S2. Durante la noche en las últimas 14 noches, ¿cuántas noches se despertó [nombre del niño/a]
por el asma, con silbidos (pitos) al respirar, falta de aire, opresión en el pecho o tos?
S2.1 ¿Y durante los últimos 12 meses? ____ Noches
Use las mismas preguntas que arriba, sustituyendo “días” con “noches.”
Las próximas dos preguntas son acerca de hospitalizaciones y idas a la sala de emergencia
durante los últimos 12 meses.
S3. Durante los últimos 12 meses (eso es desde ________), ¿[nombre del niño/a] tuvo que pasar
la noche en el hospital por el asma?
Sin contar las hospitalizaciones durante los últimos 12 meses, (eso es desde ________),
¿[nombre del niño/a] ha tenido que ir a la sala de emergencia por el asma?
_________________________________________________________________________________________
Spanish version
Preguntas sobre la exposición a eventos y programas
de la comunidad relacionados con el asma
Ahora le haré algunas preguntas acerca de su comunidad.
E1) ¿Ha oído acerca de (diga el nombre de la coalición, programa u otra organización que
corresponda)?
SÍ
NO
NO SABE
Si responde NO o NO SABE: Vaya al #3
Si responde SÍ, pregunte:
E2) ¿Cuántas veces ha participado en las actividades o recibido ayuda de (diga el nombre de la
coalición, programa u otra organización que corresponda)?
**Insista en aclarar si es a la semana, al mes, al año**
1 - ___ ___ / a la semana
2 - ___ ___ / al mes
3 - ___ ___ / al año
NUNCA
NO SABE
E3) ¿Con qué frecuencia escucha a alguien en su comunidad hablar acerca del asma?
MUY SEGUIDO/ FRECUENTEMENTE

ALGUNAS VECES
RARAS VECES
NUNCA
NO SABE
E4) Durante los últimos seis meses, ¿usted o su niño con asma han hablado con un doctor o una
enfermera acerca del asma de su niño?
SÍ
NO
NO SABE
E5) Durante los últimos seis meses, ¿los ha visitado alguien en su casa para hablar acerca del
asma de su niño?
SÍ
NO
NO SABE
_________________________________________________________________________________________
Spanish version
E6) Durante los últimos seis meses, ¿los ha llamado alguien por teléfono para hablar acerca del asma de
su niño?
SÍ
NO
NO SABE
E7) Durante los últimos seis meses, ¿usted o su hijo han asistido a una clase acerca del asma en la
escuela de su hijo?
SÍ
NO
NO SABE
E8) Durante los últimos seis meses, ¿usted o su hijo han asistido a una clase acerca del asma en algún
otro lugar como una clínica, el centro de su comunidad o iglesia?
SÍ
NO
NO SABE
E9) Durante los últimos seis meses, ¿usted o su hijo han participado en alguna otra actividad para
personas con asma tal como una feria de salud, un campamento para niños con asma o un evento en
su comunidad?
SÍ
NO
NO SABE
E10) Durante los últimos seis meses, ha asistido a una presentación acerca del asma en una iglesia u otra
organización en su comunidad?
SÍ
NO
NO SABE
E11) Durante los últimos seis meses, ¿ha recibido impresos, folletos informativos o manuales acerca del
asma?
SÍ
NO
NO SABE
E12) Durante los últimos seis meses, ¿ha visto carteles, letreros o anuncios acerca del asma en su
comunidad?
SÍ
NO
NO SABE
E13) (Opcional) Durante los últimos seis meses, ¿ha asistido a un grupo de apoyo de asma?
SÍ
NO
NO SABE
_________________________________________________________________________________________
Spanish version
Demografía
Niño/a
D1. ¿Cuál es el sexo de su niño/a? ___ Masculino ___ Femenino
D2. ¿Cuál es la edad de su niño/a y su fecha de nacimiento?
___ Edad (en años) Fecha de Nacimiento:

Mes Día Año
D3. ¿Qué es su niño/a, español/a, hispano/a, latino/a?

Sí no es español/a, hispano/a o latino/a, ponga una “X” en la caja “NO”.
___ No, no es español/hispano/latino

___ Sí, mexicano, mexicano-americano, chicano
___ Sí, puertorriqueño
___ Sí, cubano
___ Sí, otro grupo español, hispano o latino
Escriba el grupo en letra de molde______________________
D4. ¿Cuál es la raza del niño/a?

Ponga una o más “X” para indicar la raza a la que pertenece el/la niño/a, según el/la
encargado/a del cuidado del niño/a.
___ Blanca
___ Negra, africana americana
___ India americana o nativa de Alaska
___ India asiática
___ China
___ Filipina
___ Japonesa
___ Coreana
___ Vietnamita
___ Otra asiática (Escriba abajo la raza en letra de molde)
___ Hawaiano nativo
___ Guam o Chamorro
___ Samoano
___ Otra de las islas del Pacifico (Escriba abajo la raza en letra de molde)
___ Alguna otra raza (Escriba abajo la raza en letra de molde)
___________________________
D5. ¿Actualmente, tiene su niño/a seguro médico? ___ Sí ___ No

Si tiene, ¿qué seguro tiene? __________________________
_________________________________________________________________________________________
Spanish version
¿El seguro es por medio de Medicaid o CHIP (o cualquier nombre apropiado al lugar)?
__________________________
Persona encargada del cuidado del niño
D6. ¿Cuál es el código postal del área donde vive? ____________________
D7. ¿Cuál es su sexo? ___ Masculino ___ Femenino
D8. ¿Cuántos años tiene usted y cuál es su fecha de nacimiento?
___ Edad (en años) Fecha de Nacimiento:

Mes Día Año
D9. ¿Cuál es su relación con [niño/a]? ___Madre ___Padre ___Abuela ___Abuelo ___ Tío/a
____Otro: (especifique) __________________
D10. ¿Es usted español/a, hispano/a, latino/a?

Sí no es español/a, hispano/a o latino/a, ponga una “X” en la caja “NO”.
___ No, no es español/hispano/latino

___ Sí, mexicano, mexicano-americano, chicano
___ Sí, puertorriqueño
___ Sí, cubano
___ Sí, otro grupo español, hispano, latino
Escriba el grupo en letra de molde______________________
D11. ¿Cuál es su raza?

Ponga una o más “X” para indicar la raza a la que él/ella considera que pertenece.
___ Blanca
___ Negra, africana americana
___ India americana o nativa de Alaska
___ India asiática
___ China
___ Filipina
___ Japonesa
___ Coreana
___ Vietnamita
___ Otra asiática (Escriba abajo la raza en letra de molde)
___ Hawaiano nativo
___ Guam o Chamorro
___ Samoano
___ Otra de las islas del Pacifico (Escriba abajo la raza en letra de molde)
___ Alguna otra raza (Escriba abajo la raza en letra de molde) _______________________
_________________________________________________________________________________________
Spanish version
D12. ¿Cuál es el nivel más alto de educación que Ud. ha terminado?
Ponga UNA SOLA “X”.
Si Ud. está estudiando, por favor marque el nivel anterior al actual o el nivel más alto que haya
completado.
Entrevistador: No lea las respuestas. Marque la caja apropiada y tantee si es necesario.
___ No ha completado ningún grado

___ Guardería infantil (nursery school) a 4o grado
___ 5 o ó 6 o grado
___ 7 o u 8 o grado
___ 9 o grado
___ 10 o grado
___ 11 o grado
___ 12 o grado—SIN DIPLOMA
___ GRADUADO/A DE ESCUELA SECUNDARIA—
DIPLOMA de escuela secundaria o su equivalente (por ejemplo: GED)
___Alguna escuela técnica/vocacional
___Terminó escuela técnica/vocacional
___ Algunos créditos universitarios, pero menos de 1 año
___ 1 año o más de universidad, sin título
___ Título de asociado universitario (por ejemplo: AA, AS)
___ Título de bachiller universitario (por ejemplo: BA, AB, BS)
___ Título de maestría (por ejemplo: MA, MS, MEng, MEd, MSW, MBA)
___ Título profesional (por ejemplo: MD, DDS, DVM, LLB, JD)
___ Título de doctorado (por ejemplo: Ph.D, Ed.D)
___Otro (por favor describa; incluya el país donde estudió:
_________________________
D13. Antes de pagar impuestos ¿cuál fue el ingreso de su familia el año pasado?
(Opcional) _________________________
O
D14. ¿Qué categoría describe mejor el ingreso total de su familia, el año pasado, antes de pagar
impuestos? (Entrevistador: “Por favor párame cuando llegue a la categoría que describe
mejor sus ingresos totales.”)
___ Menos de $5,000
___ $5,001-$10,000
___ $10,000-$15,000
___ $15,001-$20,000
___ $20,001-$30,000
___ $30,001-$40,000
___ $40,001-$50,000
___ $50,001-$60,000
___ $60,001-$70,000
___ $70,001-$80,000
____$80,000 o más
_________________________________________________________________________________________
Spanish version
APPENDIX A:
HOW ALLIES AGAINST ASTHMA USED
THESE CROSS-SITE EVALUATION
INSTRUMENTS
Context Survey
The Context Survey provided both quantitative and qualitative information about
coalition structure and functioning, the focus of coalition efforts and information
about the social, cultural and political environment of the community in which the
coalition operates. The survey is a semi-structured telephone interview that was
conducted by the National Program Office staff with 1-3 coalition members and
staff from each of the seven sites. Context surveys were conducted at baseline with a
second administration two years later to coincide with the Coalition Self-Assessment
Survey (CSAS) administration. Analyses include content analysis of coalition
structure, community readiness, and lessons learned by the coalitions. Data from the
context interviews will also be used to help interpret responses related to coalition
processes from the CSAS.
Coalition Self-Assessment Survey (CSAS)

The Coalition Self-Assessment Survey (CSAS) was administered annually to the
coalition membership to capture quantitative information on coalition structure and
processes, including coalition functioning, leadership, and effectiveness of effort.
The survey was administered by local staff at a general membership meeting or via
U.S. mail to members attending at least two coalition meetings within the 12 months
prior to the survey.
CSAS responses from all sites were combined and analyzed descriptively, and
bivariate relationships were explored, stratified by role in coalition, site, and other
demographic variables. These results were reported to the Allies sites from the
National Program Office annually as site-specific information along with ranges of
responses from all sites combined. Reliability analysis of questions from CSAS using
categories based on previous factor analyses by Kenney and Sofaer were used to
formulate indices for further descriptive analysis, bivariate analysis, and regression
model building.
Appendix A: How Allies Used these Cross-site Evaluation Instruments 1 of 3

Key informant interview guides
Key informant interviews were conducted by a neutral contractor at two points in
time (baseline [2003] and follow-up [2005]) with a selected number of coalition staff
and leaders, coalition members, and other community leaders. Key informants inside
and outside of the coalition were selected based on their relationship to the coalition,
history within the community, professional backgrounds, and personal connections
to asthma. Interviews with 15-17 individuals from each site were intended to provide
a broad range of perspectives on the activities of each coalition. Interview guides and
key informant selection protocols were developed collaboratively with input from
each coalition and the National Program Office staff. The semi-structured interviews
were designed to collect information from the point of view of participants about the
coalition planning process, level of their involvement in the coalition, goals and
interventions, and perceptions of coalition impact. The follow-up interviews also
address change in coalition structure and membership, implementation of
interventions, and progress toward goals, including the individual’s satisfaction with
the interventions currently being implemented and perceptions of collaborations and
linkages among community-based organizations. Both the baseline and follow-up
interviews address participants’ expectations about future outcomes and their
perspectives on the value of the coalition.
The electronic records of interview data were sorted by codes based on study
questions and themes in order to analyze each specific topic qualitatively. Coded data
for each site were analyzed independently. A summary report for each site was
prepared by the contractor for both baseline and follow-up based on the interview
data and any documents collected and reviewed. The site-specific reports were
reviewed by each site prior to completion.
Program Reach
Program Reach, a password-protected, web-based, site-specific tracking system,

captured data on the extent of coalition activities. Local coalition staff entered data
to describe the activities conducted including the zip code area where the activity
took place. The database includes information such as the number and type of
program participants, topics addressed, settings in which activities were conducted,
and system changes implemented.
Program Reach data for all sites were compiled by the National Program Office staff
and will be examined to identify depth and breadth of program activities. Program

Reach data collection was ongoing throughout the implementation period; analyses
will be conducted after the implementation period.
Core Caregiver Survey

The Core Caregiver Survey is a compilation of previously existing surveys used to
measure individual health outcomes between baseline and one-year follow-up
periods and was used by Allies to measure a cohort of individuals exposed to the
coalition’s most intensive interventions and a control/comparison group.
The National Program Office will conduct baseline to follow-up analyses for
intervention and comparison groups collectively and for each coalition site. The
analyses will pool data across the coalition sites, taking into account any differences
between intervention and comparison groups at each site. Analyses of pooled data
will include both stratification and control for coalition site. Bivariate relationships
will be explored, and in particular, relationships between factors related to
symptoms, health care utilization and quality of life outcomes will be investigated.
Multi-level models will be constructed adjusting for site differences in treatments,
individuals participating in the study and study site characteristics.

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Coalition Self-Assessment Survey (CSAS) (English and Spanish; 21 pages each)

Key Informant Interview Guides (5 guides; English; total of 17 pages)

Program Reach Forms (English; 9 pages)

Core Caregiver Survey (English and Spanish; 10 pages each)

Development and Conditions of Use

1. On what date did the 2nd follow-up administration of CSAS begin?

2. On what date did the follow-up period end?

4. Describe the non-responders.

6. Briefly describe the major focus of coalition efforts:

Probe: Stage of development

7. How are decisions made within the coalition?

Probe: Approximate number of individuals who serve on each of the committees.

Probes: How many are in leadership positions?

Probes: How many? Background, skills?

16. Describe your stage of coalition readiness at this time.

Development and Conditions of Use

ALLIES AGAINST ASTHMA

For office use only

Site ID# _______

____ on-site during meeting

Allies Against Asthma 5 Coalition Self-Assessment Survey (CSAS) 2 of 45

a. Member of the steering or executive committee

Q2. Are you part of the coalition as an individual member or as a representative of an

1. Individual Member, not representing an organization

_____ YEARS _____MONTHS _____DON’T KNOW _____NOT APPLICABLE

Allies Against Asthma 5 Coalition Self-Assessment Survey (CSAS) 3 of 45

1. Community Health Center/Community clinic

_____ YEARS _____MONTHS _____DON’T KNOW _____NOT APPLICABLE

Allies Against Asthma 5 Coalition Self-Assessment Survey (CSAS) 4 of 45

1. Physician, please specify______________________________

INCLUSION, RECRUITMENT, MEMBERSHIP

Allies Against Asthma 5 Coalition Self-Assessment Survey (CSAS) 5 of 45

1. Community Health Center/Community clinic

Allies Against Asthma 5 Coalition Self-Assessment Survey (CSAS) 6 of 45

1. The coalition never tried to involve them

Q7. Is your coalition actively recruiting new members?

1. Less than one-quarter of the members

Allies Against Asthma 5 Coalition Self-Assessment Survey (CSAS) 7 of 45

No Some A Lot of Not

b) Coalition Officers or Committee Chairs 1 2 3 4

No Influence Some Influence A Lot of Influence

1. Coalition members vote, with majority rule

Not at All Somewhat Very

Allies Against Asthma 5 Coalition Self-Assessment Survey (CSAS) 8 of 45

Strongly Disagree Agree Strongly Don’t

a) The coalition has clear and explicit procedures for 1 2 3 4 5

b) The coalition follows standard procedures for 1 2 3 4 5

c) The decision-making process used by the coalition is 1 2 3 4 5

d) The decision-making process used by the coalition is 1 2 3 4 5

e) The coalition makes good decisions 1 2 3 4 5

1. More conflict than I expected

Allies Against Asthma 5 Coalition Self-Assessment Survey (CSAS) 9 of 45

None Some A Lot Don’t

b) Differences in opinion about specific objectives 1 2 3 4

c) Differences in opinion about the best strategies to achieve 1 2 3 4

e) Fighting for power, prestige and/or influence 1 2 3 4

f) Fighting for resources 1 2 3 4

g) Differences in opinion about who gets public exposure and 1 2 3 4

i) People aren’t sufficiently included in coalition 1 2 3 4

1. Open debate about opposing viewpoints

Allies Against Asthma 5 Coalition Self-Assessment Survey (CSAS) 10 of 45

Allies Against Asthma 5 Coalition Self-Assessment Survey (CSAS) 11 of 45

___ YEARS _MONTHS _DON’T KNOW ___NOT APPLICABLE

___ YEARS _MONTHS _DON’T KNOW ___NOT APPLICABLE