Peer Mentor and Peer NRFU Survey

RTI International
NPRC Outcomes Evaluation
Peer Mentor and Peer NRFU Survey1
Section 1. Introduction
The Administration for Community Living (ACL) has contracted with RTI International for an evaluation of the
National Paralysis Resource Center (NPRC), which is implemented by the Reeve Foundation. The purpose of this
evaluation is to learn more about the Reeve Foundation’s programs and what lessons can be learned to inform
other ACL programs.
As part of this evaluation, RTI needs your help. You have been specially selected to participate in this brief survey
of peer mentors and peers (mentees) of the Peer and Family Support Program at the Reeve Foundation, because
our records indicate you have not responded to our other requests to complete a survey. Whether you’ve had a
positive or negative experience, we appreciate you taking the time to respond to these 13 questions.

Section 2. Mentoring experience
(Required) Q1. Have you participated in the peer mentoring program at the Reeve Foundation?
a. Yes
b. No [PROGRAMMER: GO TO END1]
(Required) Q2. Which of the following choices best described you when you participated in the peer mentoring
program?
a. Someone living with paralysis
b. Caregiver to someone living with paralysis
Q3. Approximately when did you first become involved with the peer mentoring program?
a. 6 months ago or less
b. More than 6 months but less than 1 year ago
c. 1–2 years ago
d. More than 2 years ago
Q4. Overall, did participation in peer mentoring have the effect on your well-being that you expected?
a. Yes
b. No

Section 3. Background Information
Q5. How old are you?
a. 18 to 24
b. 25 to 34
c. 35 to 44
d. 45 to 54
e. 55 to 64
f. 65 or over
Q6. Which of the following describes you? Select all that apply.
a. American Indian/Alaska Native
b. Black/African American
c. Native Hawaiian/Pacific Islander
d. Asian
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Unless flagged, questions are not required and will only get a soft prompt encouraging them to answer to the
best of their ability.

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e. White/Caucasian
f. Some other race
99. Prefer not to answer
Q7. Are you of Hispanic, Latino, or Spanish origin or descent?
a. Yes
b. No
98. Don´t know
99. Prefer not to answer
Q8. What is the highest level of school you have completed?
a. Less than high school
b. High school or equivalent
c. Some college/university, no degree
d. College or university degree
e. Postgraduate degree
Q9. What sex were you assigned at birth, on your original birth certificate?
a. Female
b. Male
98. Don’t know
99. Prefer not to answer
Q10. What is your current gender? Female
a. Male
b. Transgender
c. [If Q29=a] Two-Spirit
d. I use a different term. (OPEN ENDED)
98. Don’t know
99. Prefer not to answer
Q11. Which of the following best represents how you think of yourself?
a. Lesbian or gay
b. Straight, that is, not gay or lesbian
c. Bisexual
d. [If Q29=a] Two-Spirit
e. I use a different term (Specify)
98. Don’t know
99. Prefer not to answer
Q12. [IF Q3=a, then question=“Please provide the approximate date of the onset of paralysis.”;
ELSE IF Q3=b, then question=“Please provide the approximate date of your caregiving role.”]
[PROGRAMMER: CALENDAR QUESTION FORMAT MONTH/YEAR]
98. Don´t know
98. Don’t know
Q13. [If Q3=a, then question=“What type of paralysis do you have? Choose one of the following answers.”
Else if Q3=b, then question= “What type of paralysis do you provide care for? Choose one of the following
answers.]
a. Paraplegia (T1 and below)
b. Hemiplegia
c. Quadriplegia (C8 and above)
d. Other (Specify)

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98. Don’t know
[GO TO END2]

Section 4. End
END1. Thank you for your willingness to participate; however, you are ineligible at this time.
END2. We thank you for your time and cooperation in this study. Your anonymous responses are very important
and will help the Administration for Community Living improve its support to resource centers nationwide.
OMB No: 0985-NEW. This activity is authorized under the Paperwork Reduction Act. Data collected will be shared
with ACL staff, but your responses will be used for research and aggregate reporting purposes only and will not be
used for other non-statistical or non-research purposes. Public reporting burden for this collection of information
is estimated to average 5 minutes, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to evaluation@acl.hhs.gov.

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