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.(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 ______
3. Did you visit the [Health Window]?
Yes ____
No ____
Don’t know ____
Refuse ____
4. What is the main idea that the [brochure, poster, video] is trying to get across, in your own words?
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 |
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 |
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.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Patricia |
File Modified | 0000-00-00 |
File Created | 2021-01-25 |