Attach 2_Example of Past Submission #2

Attachment 2: NCI Office of Advocacy Relations, Post-Activity Survey for Staff

OMB # 0925-0046

Expiry Date: 10/31/2006

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.

Dear

You recently worked with a CARRA Program Member(s) in a NCI activity. We want to get your feedback of that experience. Your feedback will be used to further develop and improve the CARRA Program at NCI.

The following post-activity questionnaire should take no more than 10 minutes to complete, and your responses will be kept confidential. 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.

We greatly appreciate your feedback and thank you for completing this questionnaire. Your input will be used to ensure that the consumer viewpoint is effectively incorporated into future NCI activities.

Sincerely,

Elizabeth Neilson

CARRA Program Manager

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 Rockville, MD 20892-8324	OR FAX TO: 1–301-480-7558 Attn: Elizabeth Neilson

All questions in this survey refer to your experience with a CARRA Member(s) for_________________________________________________________________________________. If you did not participate in this activity, or have any questions, please contact Elizabeth Neilson, CARRA Program Manager before completing the survey. Otherwise, please complete the questions below.

1. Please think about your overall experiences and interactions with CARRA Members during this activity, and consider how satisfied you were with each of the following items. For each, please rate your satisfaction on a scale of 1 to 5.

	Very satisfied				Not at all satisfied
a. The process of requesting a CARRA member(s)	1	2	3	4	5
b. The amount of time it took CARRA staff to process your request	1	2	3	4	5
c. The general level of preparation of the CARRA Member(s) who participated in this activity	1	2	3	4	5
d. The extent to which the Member(s)’ abilities and experiences were matched to the particular needs of your activity	1	2	3	4	5
e. The overall level of skills, experiences, and qualifications of the individual(s) recommended to you by the CARRA staff	1	2	3	4	5
f. The overall contribution that the CARRA Member(s) made to this activity	1	2	3	4	5

2. Below please list the CARRA Member(s) who participated in this activity.

a. First CARRA Member GO TO QUESTION 3 TO
EVALUATE THIS MEMBER’S
PERFORMANCE

b. Second CARRA Member GO TO QUESTION 4 TO
EVALUATE THIS MEMBER’S
PERFORMANCE

c. Third CARRA Member GO TO QUESTION 5 TO
EVALUATE THIS MEMBER’S
PERFORMANCE

Please rate the individual performance of the first CARRA member listed in Question 2 here.

3. On a scale of 1 to 5 with 1 being excellent and 5 being unsatisfactory, how would you rate this CARRA Member in the following areas…

	Excellent				Unsatisfactory		NA
a. Contributing verbally	1	2	3	4	5		6
b. Contributing in written form	1	2	3	4	5		6
c. Appropriately handling potential conflicts of interest	1	2	3	4	5		6
d. Seeking out information in a proactive manner	1	2	3	4	5		6
e. Maintaining confidentiality when necessary	1	2	3	4	5		6
f. Conducting him or herself in a professional way	1	2	3	4	5		6
g. Representing the consumer perspective	1	2	3	4	5		6
h. Meeting your needs for consumer involvement	1	2	3	4	5		6

Did you use a second CARRA Member? If so, go to Question 4. If not please skip to Question 6.

4. On a scale of 1 to 5 with 1 being excellent and 5 being unsatisfactory, how would you rate this CARRA Member in the following areas…

	Excellent				Unsatisfactory		NA
a. Contributing verbally	1	2	3	4	5		6
b. Contributing in written form	1	2	3	4	5		6
c. Appropriately handling potential conflicts of interest	1	2	3	4	5		6
d. Seeking out information in a proactive manner	1	2	3	4	5		6
e. Maintaining confidentiality when necessary	1	2	3	4	5		6
f. Conducting him or herself in a professional way	1	2	3	4	5		6
g. Representing the consumer perspective	1	2	3	4	5		6
h. Meeting your needs for consumer involvement	1	2	3	4	5		6

Did you use a third CARRA Member? If so, go to Question 5. If not please skip to Question 6.

5. On a scale of 1 to 5 with 1 being excellent and 5 being unsatisfactory, how would you rate this CARRA Member in the following areas…

	Excellent				Unsatisfactory		NA
a. Contributing verbally	1	2	3	4	5		6
b. Contributing in written form	1	2	3	4	5		6
c. Appropriately handling potential conflicts of interest	1	2	3	4	5		6
d. Seeking out information in a proactive manner	1	2	3	4	5		6
e. Maintaining confidentiality when necessary	1	2	3	4	5		6
f. Conducting him or herself in a professional way	1	2	3	4	5		6
g. Representing the consumer perspective	1	2	3	4	5		6
h. Meeting your needs for consumer involvement	1	2	3	4	5		6

6. What did the CARRA Member specifically contribute to this activity? How did they make a positive impact, if any?

7. Did the overall contribution of the CARRA Member(s) to your program meet your expectations?

8. Are there any specific areas in which you believe future CARRA Members should be trained?

9. Are there any other comments or statements you would like to make about the CARRA Program, or about the CARRA Members with whom you have interacted?

 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 including CARRA members in your work. We appreciate your participation in completing this questionnaire!