Form 1 NIH OOCCR Feedback Survey

OMB Control Number: 0925-0648

Expiration Date: March 31, 2018

Public reporting burden for this collection of information is estimated to average 4 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0648). Do not return the completed form to this address.

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1. The Ombudsman responded to me within one business day?

1. Yes

2. No

3. Unsure

4. N/A

2. The Ombudsman gave me an opportunity to express my concerns.

   1. Yes

   2. No

   3. Unsure

   4. N/A

3. I believe that my conversations with the Ombudsman were confidential.

   1. Yes

   2. No

   3. Unsure

   4. N/A

4. I feel that the Ombudsman was impartial when working with my case.

   1. Yes

   2. No

   3. Unsure

   4. N/A

5. After working with my Ombudsman, I felt able to effectively address my circumstance.

   1. Yes

   2. No

   3. Unsure

   4. N/A

6. I feel that the Ombudsman understood my concerns and, some, or all, of my issues have been satisfactorily resolved.

   1. Yes

   2. No

   3. Unsure

   4. N/A

7. I would use the Ombudsman’s office again.

   1. Yes

   2. No

   3. Unsure

   4. N/A

8. I would refer others to the Office of the Ombudsman.

   1. Yes

   2. No

   3. Unsure

   4. N/A

9. Which Ombudsman did you work with?

   1. Linda Brothers

   2. Rita Callahan

   3. Judith Gail

   4. Stephen Kotev

   5. David Michael

   6. Kathleen Moore

   7. Tyler Smith

   8. Unsure

   9. Other –Write in _____________

10. Please share any additional feedback about your experience working with the Ombudsman’s office.

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