Form 3320-0005(2) Roster Services - Member Questionnaire (Paper)

OMB Number: 3320-0005
Approval Expiry Date: XX/XX/XXXX

Roster Members Annual Evaluation
The U.S. Institute for Environmental Conflict Resolution evaluates all of its projects and cases. The U.S.
Institute requests your assistance with the evaluation of the Roster Program. Your responses will be used
to improve our programs and services. The average estimated reporting burden for this questionnaire is 4
minutes. This estimate includes time for reviewing the instructions and completing the questionnaire.
Send comments regarding this burden estimate or any other aspect of this collection of information to the
U.S. Institute. Information from this evaluation will not be reported in a way that individuals or
organizations can be identified. Moreover, the identity of individual respondents will be kept confidential
and will not be disclosed. The Office of Management and Budget control number that is displayed above
is currently valid and authorizes this collection of information.

Rating Scale
0

1

Not at all

2

3

4

5

6

7

8

Moderately

9

1. Using the scale above, please rate the extent to which you agree with the following
statements regarding the roster.
Rating

_____

The roster is a helpful tool for linking ECR users with qualified practitioners.

_____

I would recommend roster membership to other qualified ECR practitioners.

Please elaborate: ___________________________________________________
__________________________________________________________________
2. Do you have any additional comments or suggestions that you would like to provide
(e.g., a significant improvement that could be made to the roster program, feedback
on roster communications)?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

Thank you for taking the time to complete this questionnaire.

10

Very much so