Form 2 PCFDI Irvine's Leadership Behavior Survey

OMB No. 0915-XXXX

Expiration Date: XX/XX/201X

Public Burden Statement: 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. The OMB control number for this project is 0915-XXXX. Public reporting burden for this collection of information is estimated to average 1/6 hours per response, including the time for reviewing instructions, searching existing data sources, 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 HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-29, Rockville, Maryland, 20857.

Leadership Behavior Survey

Participant ID:

Instructions: A number of work tasks, which you might encounter on your job, are given below. Please indicate how confident you were before the PCFDI program and currently, in your ability to successfully perform each of these tasks. There are no right or wrong answers.

	Confidence Level Prior to PCFDI Program										Current Confidence Level (after PCFDI Program)
	1=No Confidence at All 10=Complete Confidence										1=No Confidence at All 10=Complete Confidence
Work in a group to solve problems	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10
Identify work problems that need to be improved	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10
Use analytic skills to collect data about work problems and recommend solutions	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10
Learn new skills related to my current job	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10
Help people from different departments determine the root cause of problems	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10
Make a difference to the effectiveness of the my workplace	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10

	Confidence Level Prior to PCFDI Program										Current Confidence Level (after PCFDI Program)
	1=No Confidence at All 10=Complete Confidence										1=No Confidence at All 10=Complete Confidence
Help my coworkers make improvements at work	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10
Help my supervisor make improvements at work	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10
Bring about changes in the way I do my work	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10
Bring about improvements in the way work is done	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10
State my opinion in group meetings	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10
State my opinion about work problems to my supervisor	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10
State my opinion about work problems to supervisors who are outside my own department	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10
Handle a more challenging job	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10
Prepare written reports about work problems	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10
Work with coworkers in a group	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10

	Confidence Level Prior to PCFDI Program										Current Confidence Level (after PCFDI Program)
	1=No Confidence at All 10=Complete Confidence										1=No Confidence at All 10=Complete Confidence
Debate my point of view in a group setting	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10
Debate my point of view with coworkers	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10
Participate in decisions concerning my work	1	2	3	4	5	6	7	8	9	10	1	2	3	4	5	6	7	8	9	10