Form 3320-0009 Program Support Services - Requester Questionnaire (Pape

OMB Number: 3320-0009
Approval Expiry Date: xx/xx/xxxx

ECR Program Support Services Evaluation
The U.S. Institute for Environmental Conflict Resolution (U.S. Institute) evaluates all of its services. As a
part of this evaluation we ask the agency representatives who have requested U.S. Institute services to
provide us with information about their experience. Your responses will be used to improve our programs
and services. The average estimated reporting burden for this questionnaire is 6 minutes. This estimate
includes time for reviewing the instructions and completing the questionnaire. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the Institute. Please note your responses to this questionnaire are confidential.
The identity of individual respondents is not recorded. The Office of Management and Budget (OMB)
number that is displayed on the cover is currently valid and authorizes this collection of information.

1. What prompted your request for services from the U.S. Institute?
______________________________________________________________
______________________________________________________________

2. What service(s) has the U.S. Institute provided?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

3. Please indicate your overall level of satisfaction with the U.S. Institute’s services:
Totally
Dissatisfied

Mostly
Dissatisfied

Somewhat
Dissatisfied

Neither
Satisfied nor
Dissatisfied

Somewhat
Satisfied

Mostly
Satisfied

Totally
Satisfied

F

F

F

F

F

F

F

Please elaborate:
_________________________________________________________________
_________________________________________________________________

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4. What are the anticipated benefits/impacts of the U.S. Institute’s services?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

5. If your work with the U.S. Institute were starting over again, what changes would
you like to see happen?
_________________________________________________________________
_________________________________________________________________

Rating Scale
0

1

2

Not at all

3

4

5
Moderately

6

7

8

9

10

Completely

6. Using the scale above, please rate your agreement with the following statements:
Rating
____

a. The services provided by the U.S. Institute have helped us or will help us determine
how best to proceed to address the environmental conflict(s)/issues(s) discussed.

____

b. Overall, the services provided by the U.S. Institute help us improve the effectiveness
of our environmental conflict resolution and collaborative problem-solving efforts.

7. Please use the space below for any additional feedback you would like to provide.
_________________________________________________________________
________________________________________________________________

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE.

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