Feedback Form and Follow-up Interview Questions

Appendix A: Stress Fact Sheet Feedback Form and Telephone Interview 07/28/2017

Form Approved

OMB No. 0923-0047

Exp. Date 12/31/2018

Did you use the Stress Fact Sheet?

Provide feedback to help ATSDR learn from your experience

Fill out this form to help ATSDR improve our stress-related materials. Send it to Ben Gerhardstein ([email protected]) or Jamie Rayman ([email protected]).

Background Information

Your name(s): Click here to enter your name.

Your telephone #: Click here to enter your phone.

Your email address: Click here to enter your email.

Environmental contamination issue/site name: Click here to enter the site name.

Site location (City/County, State or Tribal area): Click here to enter location.

Date(s) you used the fact sheet: Click to enter a date.

How did you use the fact sheet?

Check all that apply:

☐ Brought it to a site visit, public meeting, or open house/availability session

☐ Displayed it at a table at a public meeting or open house/availability session

☐ Gave it to a community member during an in-person interaction

☐ Gave it with a community leader during an in-person interaction

☐ Sent it to a community member or leader via e-mail or postal mail

☐ Discussed it with a community member or leader but they didn’t take it

☐ Used it to create a site-specific stress fact sheet

☐ Gave it to a local health provider

☐ Other: Click here to describe.

How many fact sheets were distributed in total (e.g. handed out and/or taken from display table)? Enter number.

ATSDR estimates the average public reporting burden for this collection of information as 20 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-0047).

Did anyone mention stress? Click here to enter yes or no.

If yes, how many conversations about stress did you have with:

Individuals who feel stress	Enter number.
Individuals who know others who feel stress (e.g. family member, neighbor, etc.)	Enter number.
Community leaders	Enter number.
Anyone else	Enter number.

How many fact sheets did you give out to:

Individuals who feel stress	Enter number.
Individuals who know others who feels stress (e.g. family member, neighbor, etc.)	Enter number.
Community leaders	Enter number.
Anyone else	Enter number.

Anything else you want to share?

Click here to share other feedback.

Can ATSDR staff call you to ask you a few more questions about ways we can improve our stress-related materials? It will be a short 15 minute call. Click here to enter yes or no.

Send this form to Ben Gerhardstein ([email protected]) or Jamie Rayman ([email protected]). ATSDR Region 9, 75 Hawthorne St., Suite 9410, HHS-1, San Francisco, CA 94105

Follow up phone interview questions

1. Can you tell me a little about the community and environmental contamination issue where you used the fact sheet?

Click here to describe.

2. Why did you decide to use the fact sheet?

Click here to describe.

3. Of the ways you used the fact sheet, what worked the best? What didn’t work?

Click here to describe.

4. How did people react to the fact sheet?

Click here to describe.

5. Did the “Tips” and “additional reading” materials help you prepare to talk with people about stress?

Click here to enter yes or no.

6. How could any of those materials be improved?

Click here to describe.

7. Is there anything else you want to share?

Click here to describe.