Form 10-10074a CSP Meeting Evaluation

OMB Number: 2900-0772
Estimated Burden: 10 minutes

Expiration Date: XX/XX/XXXX

Cooperative Studies Program (CSP)
Meeting Evaluation

PRA Statement: This information is collected in accordance with Section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are not required to respond to a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average 10 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. Disclosure of information involves release of statistical data and other non-identifying data for the improvement of services within the VA healthcare system and associated administrative purposes. Submission of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

What is your position? (Optional): ____________________________________

Circle one number for each statement.	Strongly Disagree	Disagree	Undecided	Agree	Strongly Agree
Meeting Preparation
1. I received sufficient information (e.g., agenda, meeting purpose, etc.) about the meeting well in advance.	1	2	3	4	5
2. I understood why this meeting was being held (e.g., information sharing, planning, problem solving, decision making, open discussion, etc.) and the specific outcomes expected.	1	2	3	4	5
3. I understood what was expected of me as a participant, and what was expected of the other participants (including the leader, coordinator, chairperson, facilitator, etc.).	1	2	3	4	5
4. I understood the intended flow of the meeting (e.g., agenda, schedule, design, etc.) and when it would end.	1	2	3	4	5
Meeting Execution
5. Presentations were informative.	1	2	3	4	5
6. Presentations were clear.	1	2	3	4	5
7. Participants listened carefully to each other.	1	2	3	4	5
8. Participants were able to express themselves openly, honestly, and directly.	1	2	3	4	5
9. Breakout sessions were well facilitated.	1	2	3	4	5
10. Agreements and/or conflicts were explored and constructively managed.	1	2	3	4	5
11. The meeting achieved its intended purpose (e.g., the agenda was followed, it ended on time).	1	2	3	4	5
12. My participation contributed to the outcomes achieved.	1	2	3	4	5

(NEXT PAGE)

Overall ratings
13. Overall, I am satisfied with this meeting and I feel my time here has been well spent.	1	2	3	4	5
14. Overall, I believe that the meeting will advance the program in the right direction.	1	2	3	4	5
15. I would look forward to another meeting like this one in the near future.	1	2	3	4	5

Please list any items you think were exceptionally good or deserve recognition about the meeting (e.g., presentations, organization, etc.).

Please list any items you think need improvement for the next meeting.

Other comments

VA Form 10-10074A