Exit Survey_English Translation

Attachment E: Exit Survey - English Translation

Form Approved

OMB No. 0920-0572

Ex. Date 12/28/2015

DISSEMINATION OF OSH MATERIALS THROUGH MEXICAN CONSULATES

EXIT SURVEY – ENGLISH TRANSLATION

Public reporting burden of this collection of information is estimated to average 15 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333: ATTN: PRA (0920-0572)

Exit Interview Guide-English

Dissemination of OSH Materials through Mexican Consulates Project

Parenthetical numbers correspond to Spanish Version of the HMTS OMB No. 0920-5072 February 2011

1. SCREEING QUESTIONS

1.(2a) In which of the following categories does your age fall:

___ under 18 years of age (If under 18 stop the interview)

___ 18-24 years of age

___ 25-34 years of age

___ 35-44 years of age

___ 45-54 years of age

___ 55-64 years of age

___ 65-74 years of age

___ 75 years of age or older

2. Have you seen [the occupational health brochures, posters, video shown in the TV here in the

consulate]? [show examples]

Yes ____

No ____ (If ‘no’ stop the interview)

Don’t know/Not Sure ______

Refused ______

2. ACCESS TO METHODS TESTED

3. Did you visit the [Health Window]?

Yes ____

No ____

Don’t know ____

Refuse ____

3. UNDERSTANDING THE MESSAGES

4. What is the main idea that the [brochure, poster, video] is trying to get across, in your own words?

4. QUALITY OF EXPERIENCE WITH METHODS TESTED

5. Did you take information from the [brochure, poster, video] with you, or leave it in the

consulate? Why?

____ Yes, they took information. Why?

____ No, they did not take information. Why?

I am going to read some questions that are answered using a scale from 1 to 5. Please listen carefully to each statement I will read and select a number between 1 and 5. Number 1 means that the answer is “not at all” and number 5 means that the answer is “very much.”

		Not at all				Very much
6	Overall, you like this [brochure, poster, video]?	1	2	3	4	5
7	You learned something new by [reading it, watching it	1	2	3	4	5
8	You trust the information in this [brochure, poster, video]	1	2	3	4	5
9	You can do what this [brochure, poster, video] suggests	1	2	3	4	5
10	You will do what this [brochure, poster, video] suggests	1	2	3	4	5
11	This [brochure, poster, video] was very clear	1	2	3	4	5

5. TO MEASURE BEHAVIORAL INTENTION

I am going to read some questions that are answered using a scale from 1 to 5. Number 1 means that the answer is “not likely at all” and number 5 means that the answer is “very likely.” Please listen carefully to each statement I will read and select a number between 1 and 5.

		Not likely at all				Very likely
12	How likely is it that you will [do what the (brochure, poster or video) advise]?	1	2	3	4	5
13	I plan on [calling/going to an organization to discuss protecting my health at work].	1	2	3	4	5
14	How likely would you be to talk about [risks you face at work] with your co-workers in the next week?	1	2	3	4	5
15	How likely is it that you will you bring up the issue of [health risks you face at work] the next time you speak with your boss?	1	2	3	4	5

This question is also answered using a scale from 1 to 5. Please listen carefully to the statement I will read and select a number between 1 and 5. Number 1 means that the answer is “strongly disagree” and number 5 means that the answer is “strongly agree.”

		Strongly disagree				Strongly agree
16	I think that [protecting your health at work] is a critical issue	1	2	3	4	5

6. DEMOGRAPHIC QUESTIONS

17 (1a) Gender ( ) Male ( ) Female

18 What is the highest level of education you have completed?

___ 3 years or less

___ 4-6 years

___ 7-9 years (junior high school)

___ 10-12 years (high school or technical school)

___ Some college or technical school

___ Received four-year college degree

___ Some post graduate studies

___ Received advanced degree

___ Other: ______________________________

19 (10a) What is your current occupational status? Would you say…?

___ Employed full time

___ Employed part time

___ Unemployed

___ Homemaker

___ Student

___ Retired, or

___ Disabled

___ Other: ________________________________

___ Don’t know/not sure (DO NOT READ)

___ Refused (DO NOT READ)

20 (11a) What is your current job title? What term would you use to describe your current profession?

___________________________________________________________________________________

21 (13a) Which of the following categories best describe your total, annual household income?

___ Under $20,000/year

___ $20,001 - $30,000/year

___ $30,001 - $40,000/year

___ $40,001 - $50,000/year

___ $50,001 - $60,000/year

___ $60,001 - $80,000/year

___ $80,001 - $100,000/year

___ Over $ 100,000/year

Thank you for your participation.

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