7 survey

OMB#: 0925-0584

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 02 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 (0925-0584). Do not return the completed form to this address.

OMB#: 0925-0584

Exp. X/XX/XXXX

H

CHS/SOL Participant Feedback

Thank you for your participation in the HCHS/SOL. We are interested in your feedback. Please take a few minutes to tell us about your experience and how we can make this a successful study for the Hispanic/Latino community.

1. How satisfied were you with the initial contact with HCHS/SOL at your home? Were you … Satisfied 1

Dissatisfied 2

2. How much did you like your visit to the HCHS/SOL center? (Place an X in 1 box)

Not at All Very Little Somewhat A lot 1 2 3 4

What aspects of your participation in HCHS/SOL did you like / not like? Please check all that apply from each list below.

3. LIKED 4. DID NOT LIKE

a. Recruitment process a. Recruitment process

b. Location/parking at center b. Location/parking at center

c. Appointment scheduling c. Appointment scheduling

d. Clinic visit d. Clinic visit

e. Instructions on equipment use e. Instructions on equipment use

5. Were the tests you received in the HCHS/SOL center explained clearly? No 0

Yes 1

6. From the explanations you received, how closely did the clinic examination meet your expectations? Was it:

Better than you expected 1

About what you expected 2

Worse than you expected 3

7. How would you rate the respect you were shown by the staff? Was it:

Good 1

Fair 2

Poor 3

8. How would you rate the friendliness and courtesy of the staff who conducted the interviews and tests? Was it: Good 1

Fair 2

Poor 3

9. How would you rate the total length of time for the examination that is from the time you arrived at the HCHS/SOL center to the time you left? Was it:

Shorter than you expected 1

What you expected 2

Longer than you expected 3

10. If a friend or relative were to be asked to take part in the HCHS/SOL, how likely would you be to recommend that they participate? Likely 1

Unlikely 2

11. Is there something we should do to make the visit to our center more comfortable?

No 0

Yes 1

If yes, please comment:

12. Is there something HCHS/SOL should do to improve the overall experience of participants?

No 0

Yes 1

If yes, please comment:

13. Do you have any additional comments?

No 0

Yes 1

If yes, please comment:

14. How did you hear about HCHS/SOL? Please check all that apply from each list below.

a. Study letter of invitation e. Newspaper article

b. Phone call from HCHS/SOL staff f. Television

c. Home visit from HCHS/SOL staff g. Health fair

d. Radio h. Community presentation

15. May HCHS/SOL send you a birthday card?

No 0

Yes 1

Thank you for being part of HCHS/SOL!

For HCHS/SOL Staff Use Only

ID NUMBER:

FORM CODE: EXE VERSION: A 10/24/08

Contact Occasion

SEQ #

Acrostic:

0a. Completion Date: // 0b. Staff ID: