Attachment 7:
OWH WHLI Online Survey
Form Approved
OMB No. 0990-
Exp. Date XX/XX/20XX
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0379. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
OWH WHLI Online Survey
Version Dated 10/10/2016
[DISPLAY WHLI LOGO AND NORC LOGO AT BOTTOM OF SCREEN]
You are part of a select group of individuals who participated in a unique program, and we would like to know how or if it has helped you. To that end, the Office on Women’s Health (OWH) is working with NORC at the University of Chicago to evaluate the Women’s Health Leadership Institute (WHLI) to determine the intermediate and long-term impacts and outcomes of the WHLI training. This evaluation will enable OWH to demonstrate the long-term effectiveness of the WHLI and further improve the training program. Your input is invaluable and this project cannot succeed without your help.
We value your time.
Completing the survey will take approximately 25 minutes. There are no foreseeable risks to your participation. However, your participation in this study is completely voluntary, and you may skip questions and stop the survey at any time without any adverse consequences. Whether or not you choose to participate in the study, or decide to withdraw at any point, will not affect you in any way. As a token of our appreciation, we will provide you with a $10 Amazon gift card for completing this survey.
Will my information be kept private?
All information collected will be kept private to the extent possible by law. While your responses will be used in a final report for the Office on Women’s Health, you and your organization will not be identified.
If you have any questions about your rights as a participant in this research study, please call the NORC IRB Manager by toll-free phone number at (866) 309-0542.
By selecting “Yes” below, you are consenting to participate in this research study.
Yes [GO TOINFO2]
No [GO TO NOCONSENT_EXIT]
Did you attend the Women’s Health Leadership Institute (WHLI) training?
Yes [GO TO SECTION1_1]
No [GO TO INELIG_EXIT]
PROGRAMMING NOTE (APPLIES TO TEXT FILLS FOR ALL APPLICABLE QUESTIONS):
“Condition A” requires present tense and is defined as [IF SECTION 1_3=yes] OR [IF SECTION 1_1=no or missing AND SECTION 1-3=no or missing AND SECTION 1_5=no or missing]
“Condition B” requires past tense and is defined as [IF SECTION1_1=yes AND SECTION1_3=no or missing] OR [IF SECTION 1_1=no or missing AND SECTION 1_3=no or missing AND SECTION 1_5=yes]
The first set of questions asks about your work experience as a Community Health Worker (CHW).
SECTION1_1
Were you working as a CHW or doing CHW work when you attended the WHLI training?
According to the American Public Health Association, CHWs go by a variety of titles, e.g., Promotora de Salud, Community Health Representatives, Community Health Aides, Peer Educators, and Patient Navigators. They can serve as a link between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. CHWs can also build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy.
Yes
No [GO TO SECTION1_3]
SECTION1_2
Thinking about a typical week, approximately what percentage of your professional time did you spend on CHW activities at the time you attended the WHLI training?
Please enter a number between 0 and 100.
______%
ALL GO TO SECTION1_3
SECTION1_3
Do you currently work as a CHW or do CHW work?
Yes
No
[If answer to Section 1_1 is “no” or “missing” (left blank) and [if Section 1_3 is “no” or “missing” (left blank)], go to SECTION 1_5]
i.e. if the person was not a CHW during the training AND is not currently a CHW
[If answer to Section 1_1 is “yes” and [if Section 1_3 is “no” or “missing” (left blank)], go to SECTION 1_6]
i.e. if the person WAS a CHW during the training BUT is currently not a CHW
Else if [If answer to Section 1_1 is “yes” or “no” or “missing” (left blank) and Section 1_3 is “yes”, go to SECTION 1_4]
SECTION1_4
Thinking about a typical week, approximately what percentage of your professional time do you currently spend on CHW activities?
Please enter a number between 0 and 100.
______%
[GO TO SECTION1_6]
SECTION1_5
Have you ever worked as a CHW or done CHW work?
Yes
No
SECTION1_6
What is your current job title or position?
SECTION1_7
Do you still work in the same organization as you did when you attended the training?
Yes
No
SECTION1_8
Do you still work in the same position as you did when you attended the training?
Yes
No
[If answer to SECT1_5 is “no”, go to SECT2_1; ELSE go to SECT1_9]
SECTION1_9
In what settings/organizations have you worked as a CHW?
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Yes |
No |
Community-Based Organization/Non-Profit Organization/Community Health Center |
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Hospital or other type of clinic |
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Indian or Tribal Health Department or Service |
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Local, County, or State Health Department |
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Health Plan/Managed Care Organization |
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Academic (including Primary, Secondary, and Post-Secondary) |
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Other (specify): |
SECTION1_10
How long [IF Condition A THEN DISPLAY “have you worked”; IF Condition B DISPLAY “did you work”] as a CHW?
Please answer in years and months (if days, round to the nearest month).
___ (Years) ___ (Months)
SECTION1_11
In which settings [IF Condition A THEN DISPLAY “do”; IF Condition B DISPLAY “did”] you work or do outreach?
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Yes |
No |
Homes |
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Neighborhood/Community-based/Community Centers |
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Migrant Labor Camps |
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Religious Organizations/Churches |
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Schools |
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Shelters |
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Clinics/Hospitals |
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Worksites |
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Other (specify): |
SECTION1_12
Please list up to three of the primary health, social, or community issues that you [IF Condition A THEN DISPLAY “work”; IF Condition B THEN DISPLAY “worked”] on as a CHW.
Top Issue 2nd Issue 3rd Issue
________ ________ ________
Accessing Health Services
Adolescent Health
Alcohol/Substance/Tobacco Use
Asthma
Behavioral or Mental Health
Cancer
Chronic Disease (Diabetes, Cancer, High Blood Pressure, Cardiovascular Disease)
Community Capacity
Communicable Disease other than HIV/AIDS
Domestic Violence/Child Abuse
Environmental Health
Health Promotion, Education, Outreach
HIV/AIDS
Injury Prevention
Maternal and Child Health
Men’s Health
Occupational Health
Older Adult Health
Oral Health
Obesity
Prevention (Nutrition)
Prevention (Physical Activity)
Refugee Health
Social Services
Women’s Health
Other (specify): _____________________
SECTION1_13
Please check the primary activities you [IF Condition A THEN DISPLAY “do”; IF Condition B DISPLAY “did”] in your work as a CHW.
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Yes |
No |
Provide social/personal support |
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Provide culturally appropriate health education and information |
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Advocate for individuals and communities |
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Assist people in accessing the services they need |
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Provide direct services, such as glucose and blood pressure testing |
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Provide skill-building workshops |
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Act as a cultural bridge between individuals/communities and the health and human services they receive |
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Participate in research studies |
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Conduct eligibility screening and enrollment |
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Other (specify): |
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SECTION1_14 – SECTION1_19
How would you describe the populations that you most commonly [IF Condition A THEN DISPLAY “serve”; IF Condition B DISPLAY “served”] ? Check ALL that apply.
SECTION1_14 Race/Ethnicity
Black / African American
American Indian / Alaska Native
Hispanic / Latino(a)
Non-Hispanic White
Asian / Pacific Islander
Other (specify): _____________________
SECTION1_15 Locale
Rural
Urban
Suburban
SECTION1_16 Income
Low Income
Middle Income
Upper Income
SECTION1_17 Gender
Women
Men
Transgender
SECTION1_18 Age
Adults (18 or older)
Adolescents (12-17)
Children (Under 12)
SECTION1_19 Migration
Non-immigrants
Immigrants
Refugees
Other (specify):________________
SECTION1_20
CHWs gain skills and education in many ways. In addition to the Women’s Health Leadership Institute (WHLI), which of the following describes your CHW training?
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Yes |
No |
I have taken leadership training |
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I have taken advocacy training |
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I have obtained skills/education in other ways (specify):
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The next set of questions asks about your experience with the Women’s Health Leadership Institute (WHLI). Please answer the questions to the best of your ability.
SECTION2_1
How did you hear about the Women’s Health Leadership Institute? Check ALL that apply.
My worksite supervisor
A Master Trainer
Another CHW
A WHLI flyer
Email from CHW program, association, or other entity
Other (specify): _____________________
SECTION2_2a-d
There are many reasons that may have had an impact on your decision to apply for the WHLI training. Please rate the importance of each of the following reasons.
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Extremely Important |
Very important |
Moderately Important |
Slightly important |
Not important at all |
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SECTION2_3
How satisfied were you with the application process for the WHLI training?
Very satisfied
Somewhat satisfied
Not satisfied at all
SECTION2_4
In which year did you attend the training?
2011
2012
2013
2014
2015
Other, specify: _________
Don’t Know
SECTION2_5
Did you receive funding from WHLI to attend the training?
Yes, it covered the entire cost [GO TO SECTION2_7]
Yes, it covered part of the cost [GO TO SECTION2_6]
No [GO TO SECTION2_6]
SECTION2_6
Did you receive funding from your employer to attend the training?
Yes, it covered the entire cost
Yes, it covered part of the cost
No
SECTION2_7
Did you get promoted following the WHLI training?
Yes
No [GO TO SECTION2_9]
SECTION2_8
To what extent do you agree your promotion was a direct result of the WHLI training?
Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree
SECTION2_9
Did you experience an increase in responsibilities at your current position following the WHLI training?
Yes
No [GO TO SECTION2_11]
SECTION2_10
To what extent do you agree your increase in responsibilities was a direct result of the WHLI training?
Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree
SECTION2_11
Did you receive a raise following the WHLI training?
Yes
No [GO TO SECTION3_1]
SECTION2_12
To what extent do you agree your raise was a direct result of the WHLI training?
Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree
The next set of questions asks about your knowledge and competencies working in your organization and/or community. Please answer the questions to the best of your ability.
SECTION3_1a-1f
To what extent do you agree or disagree that you could put the following skills into practice?
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Strongly agree |
Agree |
Neither agree nor disagree |
Disagree |
Strongly disagree |
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SECTION3_2a-f
To what extent do you agree or disagree that you could put the following skills into practice?
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Strongly agree |
Agree |
Neither agree nor disagree |
Disagree |
Strongly disagree |
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SECTION3_3a-f
To what extent do you agree or disagree that you could put the following skills into practice?
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Strongly agree |
Agree |
Neither agree nor disagree |
Disagree |
Strongly disagree |
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SECTION3_4a-f
To what extent has the WHLI training had a positive impact on your motivation, confidence, and abilities in your daily work in the following areas?
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Major impact |
Some impact |
No impact |
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The next set of questions asks about your leadership activities and their impact on your organization and community. Leadership activity is defined as engaging in activities with the intention to create positive changes (i.e., to improve service to clients by your home organization, to improve the way organizations work together to improve health services in the community, and/or to engage policy makers to address community needs) in an organization and/or community.
[IF Condition B, DISPLAY “While answering these questions, please think about the time when you were a CHW or did CHW work.”
SECTION4_1a-e
Please indicate the frequency with which you [IF Condition A, DISPLAY “engage”; IF Condition B DISPLAY “engaged”] in the following behaviors.
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Daily |
Weekly |
Monthly |
Yearly |
Less than Once a Year or Never |
Assessing needs and readiness to change in organization and community |
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SECTION4_2a-d
Please indicate the frequency with which you [IF Condition A DISPLAY “engage”; IF Condition B DISPLAY “engaged”] in the following behaviors.
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Daily |
Weekly |
Monthly |
Yearly |
Less than Once a Year or Never |
Strategic planning to address organization and community needs |
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SECTION4_3a-d
Please indicate the frequency with which you [IF Condition A DISPLAY “engage”; IF Condition B DISPLAY “engaged”] in the following behaviors.
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Daily |
Weekly |
Monthly |
Yearly |
Less than Once a Year or Never |
Partnering with other organizations |
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SECTION4_4a-c
Please indicate the frequency with which you [IF Condition A DISPLAY “engage”; IF Condition B DISPLAY “engaged”] in the following behaviors.
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Daily |
Weekly |
Monthly |
Yearly |
Less than Once a Year or Never |
Political leadership |
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SECTION4_5a-c
To what extent do you think that your leadership activities since the WHLI training have resulted in the following changes?
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Major impact |
Some impact |
No impact |
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SECTION4_6a-c
[Display if answer to any of the items in the grid above = Some impact or Major impact]
[NOTE TO PROGRAMMER: LOOP THIS QUESTION FOR EACH “SOME IMPACT OR MAJOR IMPACT RESPONSE ABOVE; ADMINSITERED UP TO 3 TIMES]
Please describe the impact that your leadership activities has had on [FILL “organizational change” OR “civil change” OR “policy change” BASED ON ANSWERS TO GRID ABOVE].
______________________________________________________________________
SECTION4_7a-j
To what extent do you agree or disagree with the following statements?
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Strongly agree |
Agree |
Neither agree nor disagree |
Disagree |
Strongly disagree |
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The next set of questions asks about the Community Action Project (CAP). Please answer the questions to the best of your ability.
SECTION5_1
Based on your experience and perspective, which of the following activities qualifies as a CAP?
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Yes |
No |
Don’t Know |
Repeated or ongoing community health education classes |
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One-time community forum/workshop |
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Community outreach |
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Community assessment |
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Ongoing support group |
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OWH Training |
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SECTION5_2
Did you start a Community Action Project (CAP) as part of the WHLI?
Yes [GO TO SECTION5_4]
No
SECTION5_3a-3j
To what extent do you agree or disagree that the following reasons explain why you did not start a CAP?
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Strongly agree |
Agree |
Neither agree nor disagree |
Disagree |
Strongly disagree |
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Other reasons (specify): |
[GO TO SECTION6_1]
SECTION5_4
What area(s) of community health did or does your CAP address?
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Yes |
No |
Active living |
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Child health |
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Disabilities |
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Elder health |
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Health policy |
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Infectious disease prevention |
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Mental health |
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Nutrition |
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Refugee health |
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STI testing |
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Violence prevention |
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Other (specify):
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SECTION5_5
Did you successfully complete this CAP?
Completed, CAP final report submitted
Completed, CAP final report not submitted
Ongoing: Moving forward with CAP activities [GO TO SECTION5_8]
Stopped unexpectedly: CAP implementation was delayed [GO TO SECTION5_7]
SECTION5_6
How long did it take you to complete the CAP from planning to completion? [GO TO SECTION5_8]
___ (Years) ___ (Months)
SECTION5_7a-7f
To what extent do you agree or disagree that the following statements explain why your CAP was delayed?
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Strongly agree |
Agree |
Neither agree nor disagree |
Disagree |
Strongly disagree |
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SECTION5_8
Which of the following activities did/does your CAP involve?
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Yes |
No |
Repeated or ongoing community health education classes |
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One-time community forum/workshop |
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Community outreach |
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Community assessment |
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Ongoing support group |
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OWH Training |
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Other (specify):
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SECTION5_9a-9f
To what extent do you agree or disagree that your CAP has resulted in the following changes in your community?
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Strongly agree |
Agree
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Neither agree nor disagree |
Disagree
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Strongly disagree |
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SECTION5_10a-10m
To what extent do you agree or disagree with the following statements?
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Strongly agree |
Agree
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Neither agree nor disagree |
Disagree
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Strongly disagree |
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The next set of questions asks about your experience with the Women’s Health Leadership Institute (WHLI) training. Please answer the questions to the best of your ability.
SECTION6_1
How would you rate the overall quality of the WHLI training?
Very satisfied
Satisfied
Neutral
Dissatisfied
Very dissatisfied
SECTION6_2a-2i
To what extent do you agree or disagree with the following statements about the WHLI training?
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Strongly agree |
Agree
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Neither agree nor disagree |
Disagree
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Strongly disagree |
Don’t know/ Don’t Remember |
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SECTION6_3
How many Master Trainers did you have during the WHLI training?
1
2
3
4 or more
Don’t Know [GO TO SECTION6_5a-5j]
SECTION6_4a-4j
[PROGRAMMER NOTE: Display the table up to three times based on the answer to the previous question.]
The next set of questions asks about the [IF SECTION6_3=1 THEN DISPLAY “Master Trainer” ELSE DISPLAY “Master Trainers”] you had during the WHLI training. [IF SECTION 6_3=4 or more, DISPLAY “Please select three of your Master Trainers to think about while answering these questions”
Thinking specifically about [IF SECTION6_3=1 THEN DISPLAY “the Master Trainer”; IF SECTION6_3=2 THEN DISPLAY “the FIRST Master Trainer” and “the SECOND Master Trainer” for the two tables loaded; IF SECTION6_3=3 OR SECTION 6_3=4 or more THEN DISPLAY “the FIRST Master Trainer”, “the SECOND Master Trainer” and “the THIRD Master Trainer” for the three tables loaded], to what extent do you agree or disagree with the following statements?
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Strongly agree |
Agree
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Neither agree nor disagree |
Disagree
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Strongly disagree |
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[GO TO SECTION6_6a-6i]
SECTION6_5a-5j
To what extent do you agree or disagree with the following statements about the WHLI Master Trainers?
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Strongly agree |
Agree
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Neither agree nor disagree |
Disagree
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Strongly disagree |
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SECTION6_6a-6i
To what extent do you agree or disagree that the following skills taught at the WHLI training were useful to your leadership activities or CAP development?
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Strongly Agree |
Agree |
Neither agree nor disagree
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Disagree |
Strongly Disagree
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Training did not address issue |
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SECTION6_7a-7m
To what extent do you agree or disagree that the following skills or resources would have helped you better incorporate leadership into your work?
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Strongly agree |
Agree
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Disagree |
Strongly disagree |
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SECTION6_8
Do you have other suggestions for improving the WHLI training?
[OPEN ENDED FIELD HERE]
The last set of questions are to help us get to know you better. Please answer the questions to the best of your ability.
SECTION7_1
What is your age?
18 to 24 years
25 to 34 years
35 to 44 years
45 to 54 years
55 to 64 years
Age 65 or older
SECTION7_2
What is your gender?
Female
Male
Transgender: male to female
Transgender: female to male
Transgender: gender non-conforming
SECTION7_3
Are you Hispanic or Latino?
No
Yes
SECTION7_4
How would you best describe your race? Check ALL that apply.
White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
Other (specify): _____________________
SECTION7_5
What is the highest level of education you have completed?
Less than high school
High school graduate / GED
Some college, no degree
Associate's degree
Bachelor's degree
Graduate or professional degree
[If the survey is terminated]
INELIG_EXIT
Thank you for your time, but unfortunately you do not qualify for this survey.
EXIT
Thank you for taking the time to complete our survey. We truly value the information you have provided. To receive your $10 Amazon gift card for completing the survey, please enter your email address below. Only NORC staff working on the Women's Health Leadership Institute Survey will have access to your email. We will never share your email with anyone outside of the study.
_____________________________________
If you would like to receive your gift card in the mail rather than through email, please check this box:
[IF BOX IS CHECKED, GO TO ADDRESS; ELSE GO TO FOLLOW_UP]
ADDRESS
Please enter your full name and address and your $10 Amazon gift card will be mailed to you within 4-6 weeks.
First name:
Last name:
Street address 1:
Street address 2 (optional):
City:
State:
Zip Code:
[GO TO FOLLOW_UP]
FOLLOW_UP
In addition, based on your responses, we may contact you about scheduling a phone interview to further discuss your participation in the Women’s Health Leadership Institute. Participation is voluntary. If you choose to participate, you will receive an additional $10 Amazon gift card for your time.
To make sure we have accurate information on file, please enter your full name and telephone number:
Name: _____________________________________ [FILL WITH FIRST NAME AND LAST NAME FROM ADDRESS ABOVE IF POPULATED]
Telephone Number: (___) ____ - _______
In the meantime, if you have any questions about the study or your responses, please contact NORC at WHLIsurvey@norc.org or 1-800-604-2698.
[GO TO THANK YOU]
WEB_EXIT
[GO TO THIS SCREEN IF RESPONDENT CLICKS “SAVE AND EXIT” BUTTON AT ANY POINT IN THE SURVEY]
Thank you for starting the WHLI Survey. If you exited by mistake, please select “Back” button below to continue the survey where you left off.
If you would like to continue at a different time, please use the link you received in the email. If you received a letter or phone call, please go to https://ccsurvey.norc.org/WHLIsurvey and enter your unique survey PIN.
THANK YOU
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Thank you for your assistance with this survey! To submit your responses, please click the “Submit” button below. Have a great day!
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Papia |
File Modified | 0000-00-00 |
File Created | 2021-01-22 |