Appendix 2 For Patients Website Post Listening Session Survey FINAL

Appendix 2: Post Patient Listening Session Survey for Patient/Caregiver Speakers 

 

 

OMB Control No. 0910-0697 

Expiration Date: 01/31/2027  

 

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control for this information collection is 0910-0697 and the expiration date is 01/31/2027. The time required to complete this information collection is estimated to average 5 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. 

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestion for reducing burden to PRAStaff@fda.hhs.gov.  

Your participation/nonparticipation is completely voluntary, and your responses will not have an effect on your eligibility for receipt of any FDA services. In instances where respondent identity is needed (e.g., for follow-up of non-responders), this information collection fully complies with all aspects of the Privacy Act and data will be kept secure to the fullest extent allowed by law. 

 

Background  

Introduction and context: Patient Affairs would like to better understand the experiences and perspectives of the patients and caregivers who participate in FDA Patient Listening Sessions. 

Objectives: We are trying to understand what aspects of the current Listening Session design work well and where there may be opportunities for improvement to maximize the usefulness of Patient Listening Sessions to both FDA staff and patients, caregivers, or their advocates. The survey can be used to measure participant’s satisfaction in participating in an FDA Patient Listening Session. 

Method of distribution: We will distribute this survey after the completion of each Patient Listening Sessions, both internally and externally requested. The Qualtrics survey link will be distributed via email to those who participated in each FDA Patient Listening Session.

 

Post Patient Listening Session Survey for Patient/Caregiver Speakers 

Thank you for participating in this brief survey! 

We are working to improve the Patient Listening Session program. This is voluntary survey. If you are comfortable, we welcome your feedback to these questions as well as any other aspect of the session not mentioned in the survey. We encourage you to forward this survey to the other speakers, as we would be very interested in learning how we could improve their experience as well. Completing the survey is completely optional. 

This survey is hosted on the Qualtrics website. By completing this survey, you are agreeing to the Qualtrics Privacy Policy. The answers that you provide to this survey are provided to the FDA Patient Affairs Staff for the purpose of improving the Patient Listening Session program. When your answers are transferred to the FDA Patient Affairs Staff, your data (answers) are subject to the FDA Third-Party Websites and Applications Privacy Policy. 

• Yes – I acknowledge the information above and I would like to complete the survey. 

 

• No – I do not wish to be subject to the Qualtrics Privacy Policy or the FDA’s Third-Party Websites and Applications Privacy Policy. I understand that by selecting this choice, I will not be able to complete this survey. 

Select the degree to which you agree or disagree with the statements below on a scale of 1 to 5, with 5 being Strongly Agree and 1 being Strongly Disagree.

 

	Strongly Disagree (1)	Disagree (2)	Neither agree nor disagree (3)	Agree (4)	Strongly agree (5)
The FDA heard my perspective during the Listening Session.
The Listening Session was valuable.
I was comfortable with sharing my experience with FDA.

 

What could be improved in preparation for a Listening Session? 

 

 

 

Is there anything else you would like to share with FDA Division Staff about your experience with your disease or health condition? 

 

  

We thank you for your time spent taking this survey. 

Your response has been recorded. 

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