Form 1 Pre-Summit Survey

National Eye Institute (NEI)

National Eye Health Education Program (NEHEP)

NEHEP Pre-Summit Survey

Revised February 15, 2023

OMB No.: 0925-0648, Expiration date: 06/2024

OMB Burden Statement

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 (0925-0648*). Do not return the completed form to this address.

Introductory Language

The purpose of this survey is to understand your and your organization’s areas of interest in preparation for the National Eye Institute’s (NEI) National Eye Health Education Program (NEHEP) Partnership Summit. Participating in this survey is completely voluntary and will take 5-10 minutes. You may choose not to participate, you can skip any question, and you can end the survey at any time. Results from this survey will be shared during the summit, but any information we collect is private under the Privacy Act — we will not identify your name or organization when sharing the results.

If you have any questions about the survey, please contact Briah Stokes at briah@communicatehealth.com.

Questionnaire

1. [Name] What is your name? ______________________________ [Open response]

2. [Organization] What organization do you represent? __________________________ [Open response]

3. [Accessibility eye health education] At your organization, how much of a priority is making eye health education more accessible for everyone — if at all?

• High priority

• Medium priority

• Low priority

• Not a priority

• I don’t know

4. [Accessibility workplace] At your organization, how much of a priority is making your workplace accessible — if at all?

• High priority

• Medium priority

• Low priority

• Not a priority

• I don’t know

5. [Healthy People 2030] I am familiar with the Healthy People 2030 vision and eye health-related objectives.

• Strongly disagree

• Somewhat disagree

• Neither disagree nor agree

• Somewhat agree

• Strongly agree

• N/A

Now we’d like to hear more about your organization’s involvement with eye health.

6. [Eye health education goals] In the coming year, what is 1 goal your organization has as it relates to eye health education? __________________________ [Open response]

7. [Eye health education barriers] What is 1 challenge your organization has as it relates to achieving that goal? __________________________ [Open response]

8. [Summit knowledge] Please rate how much you agree or disagree with the following statements:

	Strongly Disagree	Somewhat Disagree	Neither Disagree nor Agree	Somewhat Agree	Strongly Agree	N/A or don’t know
The goals of my organization are aligned with NEHEP’s goals.	1	2	3	4	5	6
I understand how my organization and NEHEP could be partners.	1	2	3	4	5	6
I understand how my organization could partner with other NEHEP partner organizations.	1	2	3	4	5	6
My organization feels connected to other NEHEP partner organizations.	1	2	3	4	5	6
My organization plans to partner with NEHEP in the future.	1	2	3	4	5	6
My organization intends to become more involved in NEHEP activities this year.	1	2	3	4	5	6

Next, we have a few questions about some of your preferences during the summit.

9. [Eye health topics] During the summit, we’ll break out into discussion circles to discuss the 9 baseline Healthy People 2030 vision objectives and how we can work together to make advances in these areas. Thinking on a scale of 1 to 4 (where 1=most interested and 4=least interested), how would you rank your interest in the following topics?

• Children’s eye health, and the following 2030 objectives:

  • Reduce vision loss in children and adolescents

  • Increase the proportion of children aged 3 to 5 years who get vision screening

• Eye health in adults, and the following 2030 objectives:

  • Increase the proportion of adults who have had a comprehensive eye exam in the last 2 years

  • Reduce vision loss from diabetic retinopathy

• Eye health in older adults, and the following 2030 objectives:

  • Reduce vision loss from cataract

  • Reduce vision loss from age-related macular degeneration

  • Reduce vision loss from glaucoma

• Vision rehabilitation/visual impairment/low vision, and the following 2030 objectives:

  • Increase the use of vision rehab services by people with vision loss

  • Increase the use of assistive and adaptive devices by people with vision loss

10. [Feedback] What, if anything, are you most excited to hear and/or learn about during this year’s summit? ______________________________ [Open response]

Thank you for your participation!