National Women's Health Week

Form Approved

OMB No. 0990-0379

Exp. Date XX/XX/20XX

National Women’s Health Week Survey

Introductory Screen 1

Hello [Participant Name],

Welcome to the Office on Women’s Health National Women’s Health Week Survey.

This survey is conducted by IMPAQ International, LLC on behalf of the Office on Women’s Health, U.S. Department of Health and Human Services.

Click “Next” to proceed.

Note: This is the first screen that the participant will see after clicking on the personalized link in the email invitation.

Introductory Screen 2

During National Women’s Health Week (NWHW) ...... (event_year) you registered ......... (organization_name) and ........... (event_name) on the Office on Women’s Health (OWH) website.

You are invited to take part in this survey because you agreed to participate in future evaluations when you registered your event.

This survey will ask questions about the resources and services you received from OWH for holding your NWHW event(s). It will also seek information on the NWHW event(s) your organization hosted.

There are no right or wrong answers. Your opinions and experiences are extremely important. The information that you and others provide will be used to improve the services provided by OWH.

The OMB Control Number for this information collection is XXXXX and the expiration date is XX/XX/XXXX.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-XXXX. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

Your participation is voluntary and will not affect your organization’s eligibility to partner with OWH. Your answers will be combined with those of others and neither your name nor the name of your organization will ever be used in reporting the results of the study. OWH will not know which individuals or organizations participated in this study.

Would you like to view the Frequently Asked Questions? (Yes/No)

(If the respondent clicks “Yes”, Frequently Asked Questions will be displayed.)

Click “Next” to begin the survey.

Note: OMB statement must appear at the bottom of the introductory screen:

Frequently Asked Questions Screen

“What is the purpose of the study?”

T he purpose of the study is to learn about your organization’s experience partnering with OWH in celebrating NWHW. The information collected will help OWH to improve the services it provides in the future to NWHW partners like you.

“What information do you intend to collect?

The survey will ask questions about the services, resources, and assistance your organization received for NWHW and the type of events your organization hosted during NWHW.

”Why should I answer the survey questions?”

We are interested in your opinions and experiences. The information you provide will help OWH to improve the services it provides to partners on future NWHWs.

“How did you get my name?”

We are contacting individuals who registered their NWHW event on the OWH website during the 2011 and/or 2012 NWHW and agreed to participate in future evaluations.

“What happens if I don’t participate?”

Your participation is voluntary and will not affect your organization’s eligibility to partner with OWH on future NWHWs.

“How long will it take to complete the survey?”

The survey is brief and should only take 15 minutes of your time. You can complete the survey at a time that is convenient for you. You also have the option to save and resume a partially completed survey.

“Are my answers confidential?”

Y our answers will be combined with those of others and neither your name nor the name of your organization will ever be used in reporting the results of the study. All personally identifiable data will be kept confidential except as required by law. Your answer to questions will not affect your organization’s eligibility to partner with OWH on future NWHWs. OWH will not know which individuals or organizations participated in this study.

Draft Survey Instrument

Organizational Information
Number	Question	Response Categories
We would like to learn about your organization and its partnership with the Office on Women’s Health (OWH) on National Women’s Health Week (NWHW).
A.1	What category best describes your organization?	Commercial business Community-based organization Government agency (federal, state, local) Medical association Health care provider Faith-based organization Recreation center Educational institution Other (specify)
A.2	What percentage of your organization’s target population includes women and girls?	Less than 10 percent 10 - 25 percent 26 - 49 percent 50 percent (no targeting by gender) 51 - 75 percent More than 75 percent Do not know
A.3	Did your organization ever receive a grant from the Office on Women’s Health for your NWHW events?	Yes No Do not know

Resources for OWH
Number	Question						Response Categories
The Office on Women’s Health (OWH) offers a variety of resources to its partner organizations related to National Women’s Health Week. The next few questions ask about which OWH resources you may have used for your NWHW ....... (event_year) event and how useful those resources were.
B.1	Did you use the NWHW activity planning resources, such as how-to guides, check-lists, fact-sheets, and templates, on the OWH website for your NWHW ....... (event_year) event?						Yes No Do not remember
B.2 CHECK IF B.1 = NO, GO TO B.2. THEN SKIP TO B.8. OTHERWISE SKIP TO B.3
B.2	What is/are the reason(s) that you did not use the NWHW activity planning resources on the OWH website? (Select all that apply.)						Did not know that there were activity planning resources Did not need these activity planning resources Could not access these activity planning resources Did not like these activity planning resources Did not have time to use these activity planning resources Do not know Other (specify)
B.3	How useful was each of these NWHW activity planning resources for your NWHW ....... (event_year) event? If you would like to refresh your memory, please click on the item to view the activity planning resource. (Select all that apply.) (The resource names below link to examples of the resources on the OWH website)
	Activity Planning Resource		Very useful	Somewhat useful		Not useful		Do not remember	Did not use
B.3a	NWHW Fact Sheet
B.3b	National Women’s Check-up Day Fact Sheet
B.3c	NWHW Registration Guide (NWHW Activity Registration and Event Planning Overview for 2012 registrants)
B.3d	Checklist for Your NWHW Event
B.3e	Ideas for Celebrating NWHW
B.3f	Tips for Building Partnerships
B.3g	How-to Guide for Media Outreach
B.3h	Proclamation Template
B.3i	Issuing and Using a Proclamation
B.3j	Media Advisory Template
B.3k	Press Release Template
B.3l	Sample Newsletter Text
B.3m	Thank You Note for Media
B.3n	How to Celebrate NWHW Online (New for 2012)
B.3o	Web buttons and banners
We will ask respondents who found a particular activity planning resource as not useful to list suggestions for improvement. Each of the items will be given as a separate question and will be posed to respondents according to their previous selection.
B.4a-o Do you have any suggestions for making (Activity Planning Resource name) more useful for your NWHW events?
	Activity Planning Resource						Suggestions (Free text)
B.4a	NWHW Fact Sheet
B.4b	National Women’s Check-up Day Fact Sheet
B.4c	NWHW Registration Guide (NWHW Activity Registration and Event Planning Overview for 2012 registrants)
B.4d	Checklist for Your NWHW Event
B.4e	Ideas for Celebrating NWHW
B.4f	Tips for Building Partnerships
B.4g	How-to Guide for Media Outreach
B.4h	Proclamation Template
B.4i	Issuing and Using a Proclamation
B.4j	Media Advisory Template
B.4k	Press Release Template
B.4l	Sample Newsletter Text
B.4m	Thank You Note for Media
B.4n	How to Celebrate NWHW Online (New for 2012)
B.4o	Web buttons and banners
B.5	Please describe other activity planning resources that you would like OWH to make available for future NWHWs, if any.						Free text
B.6	Did you use the English language activity planning resources?						Yes No Do not remember
B.7	Did you use the Spanish language activity planning resources?						Yes No Do not remember
Free publications such as health guides, and tear and share bookmarks with information on tests, exams, and immunization can be ordered from OWH when you register your NWHW event.
B.8 CHECK IF EVENT_YEAR = 2011, GO TO B.8. OTHERWISE SKIP TO B.14
B.8	Did you order free publications from OWH for your NWHW ....... (event_year) event?						Yes No Do not remember
B.9 CHECK IF B.8 =YES, GO TO B9. OTHERWISE SKIP TO B.14
B.9	How useful were the free publications for your NWHW ....... (event_year) event?						Very useful Somewhat useful Not useful Do not remember
B.10	Did the free publications you ordered arrive on time?						Yes No Do not know Do not remember
B.11	How satisfied were you with the ordering and delivery processes?						Fully satisfied Somewhat satisfied Not satisfied Do not remember
B.12 CHECK IF B.11 =NOT SATISFIED, GO TO B.12. OTHERWISE SKIP TO B.13
B.12	What changes, if any, would you like to see in future NWHWs’ ordering and delivery processes? (Select all that apply.)						Open ordering process earlier Shorten the time for order processing Speedier delivery Better packaging Other (specify)
B.13	Please describe other free publications that you would like OWH to make available for future NWHWs, if any.						None Free text
We would like to learn about the technical assistance you may have received from OWH for your NWHW event.
B.14	Did you contact OWH for technical assistance (TA) for your NWHW event?						Yes No Do not remember
B.15 CHECK IF B.14 =YES, GO TO B.15. OTHERWISE SKIP TO B.17
B.15 How satisfied were you with the help you received in each of these areas?
	Area of TA	Fully satisfied		Somewhat satisfied	Not satisfied			Do not remember	Did not use
B.15a	Media outreach
B.15b	Partnership development
B.15c	Social media
B.15d	Registration
We will ask respondents who were not satisfied with a particular TA activity to list the reasons for that assessment.
B.16 Why were you not satisfied with the help you received in the following areas?
	Area of TA						Reasons (Free text)
B.16a	Media outreach
B.16b	Partnership development
B.16c	Social media
B.16d	Registration
We would like to learn about the changes you would like to see in the NWHW registration process.
B.17	How easy or hard was it to register your event?						Very easy Easy Neither easy nor hard Hard Very Hard Do not remember
B.18 CHECK IF B.17 = HARD OR VERY HARD, GO TO B.18. OTHERWISE SKIP TO C.1
B.18	Do you have any suggestions to make it easier to register?						Free text

Sources of Information on NWHW
Number	Question	Response Categories
Please provide information on how your organization learned about NWHW.
C.1	Did your organization receive information on NWHW from any of these sources? (Select all that apply.)	Print resources (newspapers, magazines, newsletters, flyers) Radio Television Direct communication with organizations/groups/individuals, including email NWHW event womenshealth.gov website Other websites OWH Facebook page Other social networking sites such as Facebook or MySpace OWH Twitter Other Twitter feeds You Tube Blogs Do not remember Other (specify)

Promoting NWHW
Number	Question	Response Categories
Please provide information on how your organization promotes NWHW and your related events.
D.1	What are the types of media that you used to promote your NWHW ....... (event_year) event?	Print resources (newspapers, magazines, newsletters, flyers) Radio Television Direct communication with organizations/groups/individuals, including email Internet (websites, social networking sites etc.) Do not remember Other (specify)
D2. CHECK IF D.1 = INTERNET, GO TO D.2. OTHERWISE SKIP TO E.1
D.2	Which of these internet resources did you use for promoting NWHW ....... (event_year) event? (Select all that apply.)	Social networking sites such as Facebook or MySpace Twitter You Tube Websites Blogs Flickr Advertisements Do not remember Other (specify)

Types of NWHW Events
Number	Question	Response Categories
Please provide information on the events hosted by your organization during NWHW ........ (event_year).
E.1	Did your organization celebrate or promote National Women’s Check-up Day in ......... (event_year)?	Yes No Do not know
E.2 CHECK IF E.1 = YES, GO TO E.2. OTHERWISE SKIP TO E.3
E.2	How did your organization celebrate or promote National Women’s Check-up Day in ......... (event_year)?	Held a free or reduced price screening event Took the Check-up Day pledge and encouraged others to as well Distributed information related to screening tests Promoted Check-up Day through social media channels Conducted media outreach Do not know Other (specify)
E.3	Did your organization arrange for an NWHW proclamation to be issued in .......... (event_year)?	Yes No Do not know
E.4 CHECK IF E.3 = YES, GO TO E.4. OTHERWISE SKIP TO E.5
E.4	Which government agency issued the proclamation?	Governor Mayor County Official Do not remember Other (specify)
E.5	You registered (event_name) on the OWH website. What type of event was it? (Select all that apply.)	Educational activity Health fair Screening event Media outreach Social media outreach Other (specify)
E.6	Which of these health topics did ....... (event_name) address? (Select all that apply.)	Physical activity and fitness Nutrition Regular check-ups and/or preventive screenings Chronic diseases Unhealthy behaviors (e.g., smoking, not wearing a seatbelt) Mental health Health coverage or insurance Other (specify)
E.7	What was the geographical target of ....... (event_name)? (Select all that apply.)	National State City Local community Do not know Other (specify)
E.8	What was the target population of ....... (event_name)? (Select all that apply.)	Women Girls Men or boys Families Organizations Media Government Industry-specific professionals Senior citizens Minority groups Specific patient groups Disabled individuals Students Do not know Other (specify)
E.9 CHECK IF E.8 = ORGANIZATIONS, MEDIA OR GOVERNMENT, SKIP TO F.1. OTHERWISE GO TO E.9
E.9	How many individuals participated in ....... (event_name)?	Less than 50 51 - 100 101 - 250 251 - 500 501 - 1,000 1001 - 10,000 More than 10,000 Do not know

Opinions about NWHW
Number	Question	Response Categories
How much do you agree or disagree with the following statements?
		Strongly agree	Somewhat agree		Neutral		Somewhat disagree			Strongly disagree	Do not know
F.1	My NWHW event increased my organization’s ability to engage the women in my community.
F.2	My NWHW event increased my organization’s visibility in my community.
F.3	I would recommend partnering with OWH for NWHW to others.
F.4	My organization intends to partner with OWH for future NWHWs.
F.5	My organization values its partnership with OWH.
F.6	This is the logo of NWHW. Do you remember seeing the logo prior to starting this survey?									Yes No
How much do you agree or disagree with the following statements?
		Strongly agree		Somewhat agree		Neutral		Somewhat disagree			Strongly disagree
F.6a	I like the logo of NWHW.
F.6b	I like the colors of the NWHW logo.
F.6c	I like the image of flowers in the NWHW logo.
F.6d	I think the NWHW logo embodies the spirit of NWHW.
F.7	The theme for the 2011 and 2012 NWHWs was “It’s your time!” Do you remember seeing the theme before?									Yes No
F.8 How much do you agree or disagree with the following statements?
		Strongly agree		Somewhat agree		Neutral		Somewhat disagree			Strongly disagree
F.8a	I like the theme “It’s your time!”
F.8b	I think it is important to have a new theme for NWHW every year.
F.9	When I think of NWHW, I think of the Office on Women’s Health.									Strongly agree Somewhat agree Neutral Somewhat disagree Strongly disagree
F.10 How much do you agree or disagree with the following statements? Words that describe NWHW include (Select all that apply.)
			Strongly agree		Somewhat agree		Neutral		Somewhat disagree		Strongly disagree
F.10a	Nurturing
F.10b	Empowering
F.10c	Trustworthy
F.10d	Educational
F.10e	Inspirational
F.10f	Ineffective
F.10g	Unnecessary
F.10h	Other (specify)
F.11 How much do you agree or disagree with the following statements? When I think of NWHW, I think (Select all that apply.)
			Strongly agree		Somewhat agree		Neutral		Somewhat disagree		Strongly disagree
F.11a	Women must make their health a priority.
F.11b	Women can take control over their health.
F.11c	Women can take simple steps to prevent diseases and improve health.
F.11d	Women have free, evidence-based, health information available.
F.11e	Events promoting women’s health are available.
F.11f	Women’s health is a priority to government agencies.
F.11g	The community is coming together to support women’s health.
F.11h	NWHW helps women lead healthier and happier lives.

Number	Question	Response Categories
F.12	Do you have any other concerns, comments or suggestions that will improve OWH’s partnership with organizations like yours in future NWHWs?	Free text

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