Form 3320-0003(1) Assessment Services Requester Questionnaire (Rev 2011)

OMB Number: 3320-0003
Approval Expiry Date:

Assessment Services
(Requester Questionnaire)
The U.S. Institute for Environmental Conflict Resolution (U.S. Institute) evaluates all of its services. As a
part of this evaluation we ask the agency representatives who have requested U.S. Institute services to
provide us with information about their experience. Your responses will be used to improve our programs
and services. The average estimated reporting burden for this questionnaire is 5 minutes.

1. What prompted the request for consultation and upfront assessment services from the
U.S. Institute?
________________________________________________________________
_________________________________________________________________

2. Briefly describe the services the U.S Institute provided?
_________________________________________________________________
_________________________________________________________________

Rating Scale
0

1

Do not agree
at all

2

3

4

5
Moderately
agree

6

7

8

9

10
Completely
agree

3. Using the scale above, please rate the extent to which you agree with the following
statement:
Rating
____

The U.S. Institute’s services (including the contractor services, if applicable) helped
us determine how best to proceed to solve this problem/resolve this conflict.

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4. Using the scale from the previous page, please rate the extent to which you agree with
the following statements about the consultation and assessment services provided by
the U.S. Institute (including the work conducted by the contracted practitioner).
Rating
____

Key issues were explored.

____

Key issues were considered in the recommendations on how to proceed.

____

Input was sought from key parties to the situation/controversy.

____

I would use a situation/conflict assessment again for similar situations.

5. Please indicate your overall level of satisfaction with the U.S. Institute’s services:
Totally
Dissatisfied

Mostly
Dissatisfied

Somewhat
Dissatisfied

Neither
Satisfied nor
Dissatisfied

Somewhat
Satisfied

Mostly
Satisfied

Totally
Satisfied















Please elaborate:
_________________________________________________________________
_________________________________________________________________

6. What are the anticipated benefits/impacts of the U.S. Institute’s services?
___________________________________________________________________
_________________________________________________________________

7. If your work with the U.S. Institute were starting over again, what changes would you
like to see happen?
_________________________________________________________________
_________________________________________________________________

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE.

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