Follow-up Survey -Community Health workers

Appendix D
Think Cultural Health (TCH) Follow-Up Survey (Community Health Workers)

Form Approved
OMB No. 0990-0407
Exp. Date XX/XX/20XX

Appendix F
3 Month and 6 Month Follow-up Surveys for Users Who Complete One Unit
Strongly
Agree

Agree

Neither
Agree
Nor
Disagree

Disagree

Strongly
Disagree

1. In the past three/six months, I have
applied the information in Unit _ to the
work that I do.
2. My attitude about {Unit topic*} has
improved because I completed Unit _.
3. Completing Unit _ has helped me {Unit
skill**}.
4. In the past three/six months, I have
looked at the information in Unit _ again
to help me in my daily work.
5. Unit _ was relevant to my culture.
6. Taking a training in {Unit topic} was easy
to do online.
7. I would take another training related to
my work online.
8. I think other promotores de salud would
benefit from Unit _.
9. Do you have more comments about Unit _? If so, please explain them here.
*Unit Topics:
Unit A: “understanding healthy choices”
Unit B: “helping people make healthy choices”
Unit C: “understanding community change”
Unit D: “helping people make community changes”
**Unit Skills:
Unit A: “talk with someone about healthy choices”
Unit B: “teach people in your community to take action toward health”
Unit C: “make community changes”
Unit D: “empower people to make community changes”

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 0990-0407 .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