Attach 1_Example of Past Submission

Attachment 1: NCI Office of Advocacy Relations, Post-Activity Survey for Advocates

OMB # 0925-0046-08

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0046-08). Do not return the completed form to this address.

Expiry Date: 10/31/2006

Dear

You recently participated in an NCI activity as a CARRA Member. We are interested in obtaining your feedback from that experience in order to further develop and improve the CARRA Program at NCI.

The following post-activity questionnaire should take approximately 10 minutes to complete. Your participation in this survey is completely voluntary. Please be assured that if you complete this questionnaire, your responses will be kept confidential. You may skip any questions that you prefer not to answer.

Should you have questions or comments about this questionnaire, please do not hesitate to contact me via telephone: 301-451-3321 or email: neilsone@mail.nih.gov.

Thank you in advance for your participation. Your input is greatly appreciated and will be used to ensure that the consumer viewpoint is effectively incorporated into future NCI activities.

Sincerely,

Elizabeth Neilson

CARRA Program Manager

National Cancer Institute

CARRA Member Post-Activity Questionnaire

TO RETURN THE COMPLETED QUESTIONNAIRE:
E-MAIL TO: neilsone@mail.nih.gov	OR MAIL TO: Elizabeth Neilson NCI/CARRA SURVEY 6116 Executive Blvd. Room 220 MSC 8324 Bethesda, MD 20892-8324	OR FAX TO: 1–301-480-7558 Attn: Elizabeth Neilson

All questions in this questionnaire refer to your experience as a CARRA Member for the activity:_______________________________________________________________________________ If you did not participate in this activity, or have any questions, please contact Elizabeth Neilson, CARRA Program Coordinator, before completing the questionnaire.

1. Please indicate which information sources listed below you consulted to prepare for the activity prior to participating by circling the appropriate response code in Column A. Then, in Column B, please rate, on a scale of 1 to 5, how helpful each source was in preparing you for this activity.

	A. Prior to participating did you …		B. If yes, how helpful was it in preparing you for this activity
	Yes	No	Very helpful				Not at all helpful
a. Go to the CARRA web site?	1	2	1	2	3	4	5
b. Go to any other web sites? (Please specify)	1	2	1	2	3	4	5
c. Review materials sent by the activity contact person (i.e., the Scientific Review Administrator in grant review activities)?	1	2	1	2	3	4	5
d. Get information from CARRA staff?	1	2	1	2	3	4	5
e. Use any other background materials? (Please specify)	1	2	1	2	3	4	5

2. Did another CARRA Member serve as a mentor for this activity?

Yes 1 (CONTINUE TO QUESTION 3)

No 2 (SKIP TO QUESTION 4)

3. Was it helpful to have a mentor available to you?

Yes 1

No 2

Please explain:

4. To what extent did the atmosphere in which the activity was conducted support your making…

	To a great extent				Not at all		Not applicable
a. Verbal contributions?	1	2	3	4	5		6
b. Written contributions?	1	2	3	4	5		6

Please explain your answers:

5. Please consider your overall opinions about your experiences in the activity, and indicate to what extent you agree, or disagree, with each of the following statements:

	Strongly agree				Strongly disagree		Not applicable
a. The NCI contact person(s) was (were) helpful in preparing me to participate	1	2	3	4	5		6
b. My contributions were valued by other participants	1	2	3	4	5		6
c. The working environment was welcoming	1	2	3	4	5		6
d. I was provided with sufficient opportunities to express the consumer perspective	1	2	3	4	5		6

6. What did you contribute specifically as a CARRA Member to this activity? How did you make a positive impact?

7. Did your overall contribution as a CARRA Member meet your expectations?

Yes 1

No 2

Why or why not?

8. Would you be willing to participate in this type of activity again?

Yes 1

No 2

Why or why not?

9. What additional information or assistance would be helpful to prepare you to participate in this type of activity in the future?

10. Are there any other comments, statements, or insights you would like to provide about the CARRA Program?

Please check this box if you permit an Office of Advocacy Relations staff member to follow up with you regarding this experience.

Thank you for taking the time to participate in this questionnaire.
Your contribution to the CARRA Program is greatly appreciated!