Example of Survey Instrument

Form Approved: OMB Control No. 0694-0125

BIS Program Evaluation

“Seminar Title”

Location

Date

Please take a few moments to evaluate our program. Your responses will help us to structure our workshops and services to best meet the needs of the exporting community. We take your comments seriously. Thank you in advance for your time and effort.

			Poor	Fair	Average	Good	Excellent
*DAY 1*
Session Topic 1			1	2	3	4	5
Session Topic 2			1	2	3	4	5
Session Topic 3			1	2	3	4	5
*DAY 2*
Session Topic 4			1	2	3	4	5
Session Topic 5			1	2	3	4	5
Session Topic 6			1	2	3	4	5
	Overall Seminar Rating		1	2	3	4	5

OTHER:
Registration Process Rating	1	2	3	4	5
Conference Facility Rating	1	2	3	4	5

 ^{Have you previously attended any BIS programs? If yes, how many?}

_{How does this one compare?}



How long have you worked in the export control field? (Circle one)

_{Less than 1 year 1 to 3 years 3 to 5 years Over 5 years}

 ^{The information and materials presented will assist me in my [job title] responsibilities (Circle one)}

Strongly Disagree Disagree No Opinion Agree Strongly Agree

 ^{The information presented met my expectations of the goals set out in the course description. (Circle one)}

_{Strongly Disagree Disagree No Opinion Agree Strongly Agree}



How did you find out about this program?



In what city and state/country do you work?

Would you recommend the seminar to co-workers or industry colleagues? Yes No

Please indicate any suggestions you have for improvements to the workshop or topics for future workshops or any additional comments you may have about the program.

(Optional Information)

Name: Title: Company:

Telephone: Email:

Burden Estimate and Request for Comment:

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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to BIS PRA Officer, Room 6622, Bureau of Industry and Security, U.S. Department of Commerce, Washington, DC 20230, and to the Office of Management and Budget, Paperwork Reduction Project (0694-0125), Washington, DC 20503. Notwithstanding any other provision of law, no person is required to respond to nor shall a person be subject to a penalty for failure to compl y with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number.