Form Approved
OMB No. 0990-
Exp. Date XX/XX/20XX
Coalition Participants and Other Community Members Online Survey
Introduction and Informed Consent: You received this survey, because you have participated in or were provided with health information from the [Coalition] in your community. If you are 18 years or older, keep reading. Your participation is voluntary. You can skip any item you want to without penalty to you or your organization. There are little risks for your participation. Please provide honest responses and complete information. This will help the [coalition] and the U. S. Department of Health and Human Services, Office on Women’s Health in improving women and girls’ health. This should take about 10 to 20 minutes. Do not put your name on the survey or any other identifying information (other than your gender and length of time in the community, where asked). This will help us to understand the responses overall. We will mix your responses in with dozens of others and report them so that you cannot be identified. If you would like more information about this survey and your participation, please contact Dr. Suzanne Randolph at The MayaTech Corporation by email ([email protected]) or telephone (301-587-1600). She is the lead evaluator. Your local contact is: [name, title, email and/or phone]. If you have any questions regarding your participation or any aspect of this survey, please email Dr. Randolph or email Ms. Valerie Spencer ([email protected]; or call (301) 587-1600). She is President and Institutional Review Board Manager at MayaTech.
If you agree to participate in this survey, please indicate that you are 18 years or older and click “yes” below. You will, then, be directed to the survey.
If you do not agree to participate in this survey, click “No.”
I am 18 years of age or older ___YES (CONTINUE) NO___ (send to end of survey and out)
___YES, I want to participate. (CONTINUE)
___NO, I do not want to participate. (SEND TO END AND OUT OF SURVEY)
Thank you in advance for your cooperation.
Section I. Views on ways in which the community addresses the health needs of women/girls and men/boys
We would like to know your views on how organizations in your community address the health needs of women, girls, men, and boys. Please select the number that best fits your answer to each item.
1—I Strongly Disagree. 2—I Disagree. 3—I Somewhat
Disagree. 4—I am Undecided.
5-I Somewhat Agree. 6—I
Agree. 7—I Strongly Agree. 0—I Don’t Know.
In our community:
Women and men get the same benefit from health activities.
Women participate more than men in health activities.
Health activities in our community address differences between women's and men's roles.
Women have the resources they need to participate in health programs.
Health activities in our community take into account that women have needs different than men.
Health activities are supporting negative ideas about what women can do.
Organizations and agencies are working to reduce negative ideas about what women can do.
Organizations and agencies conduct activities that help community members to be more sensitive to what both men and women need to live healthier and happier lives.
Women contribute to the political decision-making in this community.
Women in this community get paid less than men for doing the same work.
Residents are aware of the difference between “sex” and “gender.”
Residents know about major differences between men’s and women’s health.
Section II. Views on Coalition Activities (for those Familiar with the Coalition)
This set of items asks about your views on the coalition’s activities and programs.
Are you aware of any of the following coalition projects [each coalition provides list, including social media or campaign messages]—CHECK ALL THAT APPLY
Did you participate in any of the coalition’s activities or programs [such as list name, social media campaign and popular name here for each site’s survey]?
___NO
___NOT SURE
___YES: Which one(s)?
If you answered “Yes” to #12, do you feel your health has improved in any area as a result of participation in the coalition’s programs?
___NO (skip to 27)
___YES: In which areas of your health?
How familiar are you with the activities and programs of the coalition?
__1--Not at all familiar (SKIP next section and go to Section III, then submit)
__2--Somewhat familiar
__3--Familiar
__4--Very familiar
[NOTE: If participant answered “somewhat familiar,” “familiar” or “very familiar” to item above, they will be directed to continue to the next set of items that asks about coalition activities].
To what extent would you say the larger community is aware of the activities and programs of the coalition?
1—Not at all aware 2—Somewhat aware 3—Unsure 4--Aware 5—Very aware
To what extent is the coalition making a difference in improving women and girls’ health in your community?
1—No difference at all 2—A little difference 3—Unsure
4—Somewhat of a difference 5—A great deal of
difference
For each of the following items, please provide the response that best fits your view for that item.
1—I Strongly Disagree. 2—I Disagree. 3—I Somewhat Disagree. 4—I am Undecided. 5-I Somewhat Agree. 6—I Agree. 7—I Strongly Agree. 0—I Don’t Know.
Females were included in the coalition activities.
Males were included in the coalition activities.
The coalition’s activities are reducing negative images about what women do.
Men and women benefit about the same from coalition activities.
There are enough resources available to women and girls to participate in coalition activities.
Both women and men have fair access to the resources they need to participate in the coalition activities.
There are possible negative effects of participation for women.
The coalition has adequate approaches to address the needs of women and girls.
Women benefit more than men from the coalition’s activities.
Provide the response that best fits your views on each of the next items.
1—I Strongly Disagree. 2—I Disagree. 3—I Somewhat Disagree. 4—I am Undecided. 5-I Somewhat Agree. 6—I Agree. 7—I Strongly Agree. 0—I Don’t Know.
The coalition’s activities can be easily tried out by others that have not yet participated.
It is easy for a man or boy to participate in coalition activities.
It is easy for a woman or girl to participate in coalition activities.
The coalition activities fit with the life circumstances of the participants/families for whom it was designed.
The immediate benefit of the intervention program for females is visible or observable.
I would recommend the coalition activities to other community residents for participation.
Others can see the difference that the coalition is making in improving women and girls’ health in our community.
Others can see the difference that the coalition is making in reducing negative stereotypes about women and girls.
SECTION III. YOUR BACKGROUND and HEALTH
Are you?: ___Female __Male __Other
Are you Hispanic or Latino/Latina? ___Yes ___No
What is your race? (Check all that apply):
__American Indian or Alaska Native
__Asian
__Black or African American
__Native Hawaiian or Other Pacific Islander
__White
How long have you lived in this community (that is, the general vicinity or area in which the coalition activities are located)? If you do not live in the specific area, but work there or have another connection which attaches you to the community, what is the length of time to which we are referring?
____Years ____Months
How would you rate your health today?
__1—Excellent 2—Very Good 3—Good 4--Fair 5—Poor
Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?
____ Number of days
Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
____ Number of days
During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?
____ Number of days
Compared to three years ago, would you say that your health has:
1—Declined
2—Stayed about the
same, still unhealthy
3—Stayed
about the same, still healthy
4—Improved
Please indicate for each of the following the response that best reflects what you know about the topic.
a. I am knowledgeable about the difference between “sex” and “gender.”
1—Not at all 2--Somewhat 3-Very
b. I am knowledgeable about the significant differences between men’s and women’s health.
1—Not at all 2--Somewhat 3-Very
Thank you for your cooperation. Office on Women’s Health will provide a summary of the results for our community to the project director of the coalition to share with in our community.
SUBMIT
Coalition Participants and
Other Community Members Online Survey
| File Type | application/msword |
| Author | ray |
| Last Modified By | Department of Health and Human Services |
| File Modified | 2015-10-26 |
| File Created | 2015-10-26 |