0703-NSAP_Questionnaire_11.30.2022

Formative Research for the Adaptation of a Risky Drinking and Sexual Assault Prevention
Program Questionnaire
PRIVACY ACT STATEMENT
AUTHORITY:
32 CFR Part 219, Protection of Human Subjects; 45 CFR Part 46, Protection of Human Subjects;
DoDI 3216.02, "Protection of Human Subjects and Adherence to Ethical Standards in DoDSupported Research," October 20, 2011; 45 CFR Parts 160 and 164, Health Insurance Portability
and Accountability Act (HIPAA) Privacy and Security Rules; and E.O. 9397 (SSN), as amended.
PURPOSE:
Information is collected to enhance basic medical knowledge, or develop tests, procedures, and
equipment to improve diagnosis, treatment, or prevention of illness, injury, or performance
impairment under research protocol NHRC,2022,0004, entitled "Formative Research for the
Adaptation of a Risky Drinking and Sexual Assault Prevention Program."
ROUTINE USES:
In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of
1974, the DoD "Blanket Routine uses" under 5 U.S.C. 552a(b)(3) apply to this collection.
Medical research information will be used for analysis and reports by the Department of the
Navy and Defense, and other U.S. Government agencies, provided this use is compatible with
the purpose for which the information was collected. Use of the information may be granted to
non-Government agencies or individuals by the Navy Surgeon General following the provisions
of the Freedom of Information Act or as may be indicated in the accompanying Informed
Consent Form.
DISCLOSURE:
Provision of information is voluntary. There are no penalties for not providing requested
information, but failure to provide the requesting information may result in failure to be accepted
as a research volunteer in an experiment or removal from the program.

Naval Health Research Center
IRB NUMBER: NHRC.2022.0004
IRB APPROVAL DATE: 11/30/2022

Demographics

Your branch:
Navy
Marine Corps
Army

Gender:

Male
Female

Do you consider yourself to be Hispanic or Latino?
Yes
No

What is your race? (Please check one or more):
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Naval Health Research Center
IRB NUMBER: NHRC.2022.0004
IRB APPROVAL DATE: 11/30/2022

Cadet year:
Year 1 Cadet
Year 2 Cadet
Year 3 Cadet
Year 4 Cadet

Paygrade/rank:
E1-E3
E4-E5
E6-E9
W1-W5
O1-O3
O4 or higher

Years on active duty:
Less than 1
1-3
4-6
7 or more
Ratings of the Interventions
Sexual Assault Prevention Training
After reviewing the 1st presentation material, please answer the following questions.

How relevant do you think this information is to you as an active duty service member or cadet?
Not at all
relevant

Fairly
irrelevant

Naval Health Research Center
IRB NUMBER: NHRC.2022.0004
IRB APPROVAL DATE: 11/30/2022

Somewhat
irrelevant

Neither
relevant nor
irrelevant

Somewhat Fairly relevant
relevant

Extremely
relevant

Overall, how would you rate the quality of this presentation material?
Poor

Very poor

Fair

Good

Very good

Excellent

Exceptional

Sexual Assault Prevention Training
After reviewing the 2nd presentation material, please answer the following questions.

How relevant do you think this information is to you as an active duty service member or cadet?
Not at all
relevant

Fairly
irrelevant

Somewhat
irrelevant

Neither
relevant nor
irrelevant

Somewhat Fairly relevant
relevant

Extremely
relevant

Overall, how would you rate the quality of this presentation material?
Very poor

Poor

Fair

Good

Very good

Excellent

Exceptional

Sexual Assault Prevention Training
After reviewing the 3rd presentation material, please answer the following questions.

How relevant do you think this information is to you as an active duty service member or cadet?
Not at all
relevant

Fairly
irrelevant

Somewhat
irrelevant

Neither
relevant nor
irrelevant

Somewhat Fairly relevant
relevant

Extremely
relevant

Overall, how would you rate the quality of this presentation material?
Very poor

Naval Health Research Center
IRB NUMBER: NHRC.2022.0004
IRB APPROVAL DATE: 11/30/2022

Poor

Fair

Good

Very good

Excellent

Exceptional

How can the relevancy of the intervention to you as an active duty service member or
cadet be improved?

Other comments:

eCHECKUPTOGO (alcohol misuse prevention training)
After reviewing the 1st presentation material, please answer the following questions.

How relevant do you think this information is to you as an active duty service member or cadet?
Not at all
relevant

Fairly
irrelevant

Somewhat
irrelevant

Neither
relevant nor
irrelevant

Somewhat Fairly relevant
relevant

Extremely
relevant

Overall, how would you rate the quality of this presentation material?
Very poor

Poor

Fair

Good

Very good

Excellent

eCHECKUPTOGO (alcohol misuse prevention training)
After reviewing the 2nd presentation material, please answer the following questions.

Naval Health Research Center
IRB NUMBER: NHRC.2022.0004
IRB APPROVAL DATE: 11/30/2022

Exceptional

How relevant do you think this information is to you as an active duty service member or cadet?
Not at all
relevant

Fairly
irrelevant

Somewhat
irrelevant

Neither
relevant nor
irrelevant

Somewhat Fairly relevant
relevant

Extremely
relevant

Overall, how would you rate the quality of this presentation material?
Very poor

Poor

Fair

Good

Very good

Excellent

Exceptional

How can the relevancy of the intervention to you as an active duty service member or cadet be
improved?

Other comments:

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Naval Health Research Center
IRB NUMBER: NHRC.2022.0004
IRB APPROVAL DATE: 11/30/2022