Form 1 Participant Feedback

Public reporting burden for this collection of information is estimated to average 12 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. xx/xx/xxxx

HCHS/SOL- Visit 2- Participant Feedback
Contact
Occasion

FORM CODE: PFE
VERSION: 1 , 12/10/2013

ID NUMBER:

0

2

SEQ #

ADMINISTRATIVE INFORMATION
0a.

/

Completion Date:

/

0b.

Staff ID:

Instructions: Enter the answer given by the participant for each response. Use the CDART Notelog window to code
'Don’t know/refused, Missing, etc.' for those questions that do not list these as an option.

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. What are the main reason(s) for your continued participation in the HCHS/SOL study?
a. To help my community
b. To learn more about my health and what questions to ask my doctor
c. To receive the monetary incentive
d. To receive free medical tests and referrals
e. To have an opportunity to participate in other studies
f. Other
Specify:

No
0
0
0
0
0
0

Yes
1
1
1
1
1
1

2. Overall, how motivated are you to continue participating with the study?
Very motivated

3

Motivated

2

3. For the past several years, we have contacted you every year to
follow-up and see how you are doing. Please let us know how
satisfied you were with the following:

Not Motivated
Not
Satisfied

1
Very
Satisfied

Satisfied

a. The opportunity to be interviewed in either English or Spanish

1

2

3

b. The respect and professionalism of the staff

1

2

3

c. The health information and community resources received

1

2

3

d. The length of time required to complete each follow-up
interview

1

2

3

4. Have you experienced any of the following during your visit:

No

Yes

a. Problems communicating with the staff

0

1

b. Difficulty finding transportation to the clinic

0

1

c. Difficulty or discomfort with the clinic visit and the tests

0

1

d. Unfriendly or disrespectful staff

0

1

PFE-Participant Feedback-12-10-2013.docx

1 of 2

FORM CODE: PFE
VERSION: 1, 12/10/2013

ID NUMBER:

Contact
Occasion

0

2

SEQ #

5. At times, it has been difficult to continue regular contact with the study because…
a.
b.
c.
d.
e.
f.

No
0
0
0
0
0
0

I have changed my address or phone number many times
I have many family obligations
I am not very interested in the study
The study is time consuming
I have a busy work schedule
Other
Specify:__________________________

6. Throughout the year, we like to stay in touch by mailing you study
updates. How much do you like receiving the following?

Very
Little

Somewhat

Yes
1
1
1
1
1
1

Very
Much

a. ¡Salud SOL! Newsletters

1

2

3

b. Cards such as: Thank you /Birthday/Holiday/Sorry I missed you

1

2

3

c. Annual Follow-Up Reminder letter

1

2

3

d. Health Education Materials

1

2

3

e. Other

1

2

3

Please specify:___________________
7. Do you have any additional comments?
No
0

Yes
1

If yes, please write comment:

Thank you for being part of HCHS/SOL!

PFE-Participant Feedback-12-10-2013.docx

2