Online Survey-All CHWs

Attachment 7:

OWH WHLI Online Survey

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0379. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

OWH WHLI Online Survey

List of Preload Variables Needed:

P_CAP

0=Sampled person did not complete a CAP

1=Sampled person completed a CAP

Text to display at the bottom of each screen:

For technical assistance, please contact NORC at [email protected] or call 1-800-604-2698.

HOMEPAGE

Welcome to the Women’s Health Leadership Institute Survey!

You are part of select group of women who participated in a unique program, and we would like to know how or if it has helped you. To that end, the Office on Women’s Health (OWH) is working with NORC at the University of Chicago to evaluate the Women’s Health Leadership Institute (WHLI) to determine the intermediate and long-term impacts and outcomes of the WHLI training. This evaluation will enable OWH to demonstrate the long-term effectiveness of the WHLI and further improve the training program. Your input is invaluable and this project cannot succeed without your help. As a token of our appreciation, we will provide you with a $20 Amazon gift card for completing this survey.

We value your time. Completing the survey will take approximately 25 minutes. There are no foreseeable risks to your participation. However, your participation in this study is completely voluntary, and you may skip questions and stop the survey at any time without any adverse consequences. Whether or not you choose to participate in the study, or decide to withdraw at any point, will not affect you in any way. All information collected will be kept private to the extent possible by law. While your responses will be used in a final report for the Office on Women’s Health, you and your organization will not be identified. Please click below to begin the survey. If you have any questions about your rights as a participant in this research study, please call the NORC IRB Manager by toll-free phone number at (866) 309-0542. If you have any questions about this project, please feel free to call 1-800-604-2698 or e-mail [email protected] for assistance.

By clicking the “begin survey” button below, you are consenting to participate in this research study.

• Yes [GO TO SCREENER1]

• No [GO TO NOCONSENT_EXIT]

Button: BEGIN SURVEY

[DISPLAY WHLI LOGO AND NORC LOGO AT BOTTOM OF SCREEN]

SCREENER1

You have been selected to participate in this survey as a former attendee of the WHLI. Before continuing, please confirm the following:

Did you attend the Women’s Health Leadership Institute training?

• Yes [GO TO SECTION1_1]

• No [GO TO INELIG_EXIT]

SECTION 1: Work Experience

The first set of questions asks about your work experience as a Community Health Worker (CHW).

SECTION1_1

Were you working as a CHW or doing CHW work when you attended the WHLI training?

According to the American Public Health Association, CHWs go by a variety of titles, e.g., Promotora de Salud, Community Health Representatives, Community Health Aides, Peer Educators, and Patient Navigators. They can serve as a link between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. CHWs can also build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy.

• Yes

• No [GO TO SECTION1_3]

SECTION1_2

Thinking about a typical week, approximately what percentage of your professional time did you spend on CHW activities?

______%

SECTION1_3

Do you currently work as a CHW or do CHW work?

• Yes

• No [GO TO SECTION1_5]

SECTION1_4

Thinking about a typical week, approximately what percentage of your professional time do you spend on CHW activities?

______%

[GO TO SECTION1_7]

SECTION1_5

Have you ever worked as a CHW or done CHW work?

• Yes [GO TO SECTION1_7]

• No

SECTION1_6

What is your current job title or position? [GO TO SECTION2_1]

_______________________

SECTION1_7

Do you still work in the same organization as you did when you attended the training?

• Yes

• No

SECTION1_8

Do you still work in the same position as you did when you attended the training?

• Yes

• No

SECTION1_9

In what settings/organizations have you worked in as a CHW?

	Yes	No
Community-Based Organization/Non-Profit Organization/Community Health Center
Hospital or other type of clinic
Indian or Tribal Health Department or Service
Local, County, or State Health Department
Health Plan/Managed Care Organization
Academic (including Primary, Secondary, and Post-Secondary)
Other (specify):

[Load language in brackets if the respondent indicates they no longer work as a CHW]

SECTION1_10

How long [IF SECTION1_3=1 THEN DISPLAY “have you worked”; ELSE DISPLAY “did you work”] as a CHW (round to nearest month if in days)?

___ (Years) ___ (Months)

SECTION1_11

In which settings [IF SECTION1_3=1 THEN DISPLAY “do”; ELSE DISPLAY “did”] you work or do outreach?

	Yes	No
Homes
Neighborhood/Community-based/Community Centers
Migrant Labor Camps
Religious Organizations/Churches
Schools
Shelters
Clinics/Hospitals
Worksites
Other (specify):

SECTION1_12

Please list up to three of the primary health, social, or community issues that you [IF SECTION1_3=1 THEN DISPLAY “work”; IF SECTION1_3=2 THEN DISPLAY “worked”] on as a CHW.

Top Issue 2^nd Issue 3^rd Issue

________ ________ ________

1. Accessing Health Services

2. Adolescent Health

3. Alcohol/Substance/Tobacco Use

4. Asthma

5. Behavioral or Mental Health

6. Cancer

7. Chronic Disease (Diabetes, Cancer, High Blood Pressure, Cardiovascular Disease)

8. Community Capacity

9. Communicable Disease other than HIV/AIDS

10. Domestic Violence/Child abuse

11. Environmental Health

12. Health Promotion, Education, Outreach

13. HIV/AIDS

14. Injury Prevention

15. Maternal and Child Health

16. Men’s Health

17. Occupational Health

18. Older Adult Health

19. Oral Health

20. Obesity

21. Prevention (Nutrition)

22. Prevention (Physical Activity)

23. Refugee Health

24. Social Services

25. Women’s Health

26. Other (specify): _____________________

SECTION1_13

Please check the primary activities you [do/did] in your work as a CHW.

	Yes	No
Provide social/personal support
Provide culturally appropriate health education and information
Advocate for individuals and communities
Assist people in accessing the services they need
Provide direct services, such as glucose and blood pressure testing
Provide skill-building workshops
Act as a cultural bridge between individuals/communities and the health and human services they receive
Participate in research studies
Conduct eligibility screening and enrollment
Other (specify):

How would you describe the populations that you most commonly serve [served]? Check ALL that apply.

SECTION1_14 Race/Ethnicity

• Black / African American

• American Indian / Alaska Native

• Hispanic / Latino(a)

• Non-Hispanic White

• Asian / Pacific Islander

• Other (specify): _____________________

SECTION1_15 Locale

• Rural

• Urban

• Suburban

SECTION1_16 Income

• Low Income

• Middle Income

• Upper Income

SECTION1_17 Gender

• Women

• Men

SECTION1_18 Age

• Adults (18 or older)

• Adolescents (12-17)

• Children (Under 12)

SECTION1_19 Migration

• Non-immigrants

• Immigrants

• Refugees

• Other (specify):________________

SECTION1_20

CHWs gain skills and education in many ways. In addition to the Women’s Health Leadership Institute (WHLI), which of the following describes your CHW training?

	Yes	No
I have taken leadership training
I have taken advocacy training
I have obtained skills/education in other ways (specify):

SECTION 2: WHLI Training Participation

The next set of questions asks about your experience with the Women’s Health Leadership Institute (WHLI). Please answer the questions to the best of your ability.

SECTION2_1

How did you hear about the Women’s Health Leadership Institute? Check ALL that apply.

• My worksite supervisor

• A Master Trainer

• Another CHW

• A WHLI flyer

• Email from CHW program, association, or other entity

• Other (specify): _____________________

SECTION2_2a-d

There are many reasons that may have had an impact on your decision to apply for the WHLI training. Please rate the importance of each of the following reasons.

	Extremely Important	Very important	Moderately Important	Slightly important	Not important at all
My desire to address community needs.
My desire to improve my skills in my daily work.
My desire to become more confident in my work.
My desire to be more efficient in my work.

SECTION2_3

How satisfied were you with the application process for the WHLI training?

• Very satisfied

• Somewhat satisfied

• Not satisfied at all

SECTION2_4

In which year did you attend the training?

• 2011

• 2012

• 2013

• 2014

• 2015

• Don’t Know

SECTION2_5

Did you receive funding from WHLI to attend the training?

• Yes, it covered the entire cost [GO TO SECTION2_7]

• Yes, it covered part of the cost [GO TO SECTION2_6]

• No [GO TO SECTION2_6]

SECTION2_6

Did you receive funding from your employer to attend the training?

• Yes, it covered the entire cost

• Yes, it covered part of the cost

• No

SECTION2_7

Did you get promoted following the WHLI training?

• Yes

• No [GO TO SECTION2_9]

SECTION2_8

To what extent do you agree your promotion was a direct result of the WHLI training?

• Strongly agree

• Agree

• Neither agree or disagree

• Disagree

• Strongly disagree

SECTION2_9

Did you experience an increase in responsibilities at your current position following the WHLI training?

• Yes

• No [GO TO SECTION2_11]

SECTION2_10

To what extent do you agree your increase in responsibilities was a direct result of the WHLI training?

• Strongly agree

• Agree

• Neither agree or disagree

• Disagree

• Strongly disagree

SECTION2_11

Did you receive a raise following the WHLI training?

• Yes

• No [GO TO SECTION3_1]

SECTION2_12

To what extent do you agree your raise was a direct result of the WHLI training?

• Strongly agree

• Agree

• Neither agree or disagree

• Disagree

• Strongly disagree

SECTION 3: Knowledge and Competencies

The next set of questions asks about your knowledge and competencies working in your organization and/or community. Please answer the questions to the best of your ability.

SECTION3_1a-1f

To what extent do you agree or disagree that you can [could] put the following skills into practice?

	Strongly agree	Agree	Neither agree or disagree	Disagree	Strongly disagree
Build group consensus and facilitate dialogue and open communication.
Involve and organize groups to build a shared vision through collective action.
Map the decision-making process of an organization or institution.
Map the power structures that influence the decision-making process in a community.
Inform and influence formal or informal power structures.
Formulate vision and mission statements.

SECTION3_2a-f

To what extent do you agree or disagree that you can [could] put the following skills into practice?

	Strongly agree	Agree	Neither agree or disagree	Disagree	Strongly disagree
Identify social determinants of health and health disparities.
Identify agents of change that have power in a community.
Collaborate with agents of change that have power in a community.
Evaluate a community’s capacity and readiness to implement changes.
Formulate appropriate strategies for social change.
Deal with conflict as an opportunity for change.

SECTION3_3a-f

To what extent do you agree or disagree that you can [could] put the following skills into practice?

	Strongly agree	Agree	Neither agree or disagree	Disagree	Strongly disagree
Develop personal strategies to achieve effective and sustained leadership.
Draw upon cultural strengths to develop leadership.
Develop an action plan or advocacy plan.
Develop objectives for an action plan or advocacy plan.
Develop a marketing or dissemination plan that includes a broad audience.
Implement an action plan or advocacy plan.

SECTION3_4a-f

To what extent has the WHLI training had a positive impact on your motivation, confidence, and abilities in your daily work in the following areas?

	Major impact	Some impact	No impact
My motivation to address issues in my organization.
My motivation to address issues in the community.
My confidence of addressing issues in my organization successfully.
My confidence of addressing issues in the community successfully.
My ability to address issues in my organization.
My ability to address women’s health issues in the community.

SECTION 4: Leadership Activities and Impact

The next set of questions asks about your leadership activities and their impact on your organization and community. Leadership activity is defined as engaging in activities with the intention to create positive changes (i.e., to improve service to clients by your home organization, to improve the way organizations work together to improve health services in the community, and/or to engage policy makers to address community needs) in an organization and/or community.

SECTION4_1a-e

Please indicate the frequency with which you engage [engaged] in the following behaviors.

	Daily	Weekly	Monthly	Yearly	Less than Once a Year or Never
Assessing needs and readiness to change in organization and community
Initiate efforts to assess my organization’s needs or priorities.
Evaluate my organization’s capacity and readiness to implement changes.
Initiate efforts to assess the community’s needs or priorities.
Evaluate the community’s capacity and readiness to implement changes.
Identify social determinants of health and health disparities in the community.

SECTION4_2a-d

Please indicate the frequency with which you engage [engaged] in the following behaviors.

	Daily	Weekly	Monthly	Yearly	Less than Once a Year or Never
Strategic planning to address organization and community needs
Formulate appropriate strategies and develop an action plan or advocacy plan to address my organization’s needs.
Implement an action plan or advocacy plan to address my organization’s needs.
Formulate appropriate strategies and develop an action plan or advocacy plan to address the community’s needs.
Implement an action plan or advocacy plan to address the community’s needs.

SECTION4_3a-d

Please indicate the frequency with which you engage [engaged] in the following behaviors.

	Daily	Weekly	Monthly	Yearly	Less than Once a Year or Never
Partnering with other organizations
Involve other organizations to build a shared vision through collective action.
Partner with other community leaders, agencies, and groups to address a community need.
Partner with new agencies or leaders to address a community need.
Partner with an agency that would not normally be “on my side” to meet a community need.

SECTION4_4a-c

Please indicate the frequency with which you engage [engaged] in the following behaviors.

	Daily	Weekly	Monthly	Yearly	Less than Once a Year or Never
Political leadership
Get involved in policymaking or government affairs to address a community need.
Engage policymakers to address a community need.
Advocate for policy change to address a community need.

SECTION4_5a-c

To what extent do you think that your leadership activities since the WHLI training have resulted in the following changes?

	Major impact	Some impact	No impact
Organizational change: Created positive changes in policy and/or structure in my home organization.
Civil change: Positively changed the way organizations work together to improve health services in the community.
Policy change: Resulted in policy changes at the local, state, or national level.

SECTION4_6a-c

[Load if answer to previous question = Some impact or Major impact]

Please describe the impact that your leadership activities has had on [ORGANIZATIONAL CHANGE/CIVIL CHANGE/POLICY CHANGE].

[NOTE TO PROGRAMMER: LOOP THIS QUESTION FOR EACH “SOME IMPACT OR MAJOR IMPACT RESPONSE ABOVE; ADMINSITERED UP TO 3 TIMES]

______________________________________________________________________

SECTION4_7a-j

To what extent do you agree or disagree with the following statements?

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
My employer/supervisor is/was supportive of my leadership activities (e.g., funding and resources).
My organization is/was reputable in the community.
I am/was passionate towards addressing community needs.
The community is/was not interested in changes.
I have/had good existing relationships with partnering agencies.
I am/was familiar with the community issues and needs.
I am/was familiar with the community culture.
I have/had support and interest from the community.
I have/had a trusting relationship with the community.
I don’t/didn’t feel empowered to take a leadership role in my organization

SECTION 5: CAP and Impact

The next set of questions asks about the Community Action Project (CAP). Please answer the questions to the best of your ability.

SECTION5_1

Based on your experience and perspective, which of the following activities qualifies as a CAP?

	Yes	No	Don’t Know
Repeated or ongoing community health education classes
One-time community forum/workshop
Community outreach
Community assessment
Ongoing support group
OWH Training
Other (specify):

SECTION5_2

Did you start a Community Action Project (CAP) as part of the WHLI?

• Yes [GO TO SECTION5_4]

• No

SECTION5_3a-3j

To what extent do you agree or disagree that the following reasons explain why you did not start a CAP?

	Strongly agree	Agree	Neither agree or disagree	Disagree	Strongly disagree
The CAP requirements/ guidelines were not clear.
There was not enough technical support from the Master Trainers and/or WHLI.
There was not enough funding provided by my supervisor or organization to support a CAP.
I did not feel prepared to complete a CAP after the training.
I could not identify a community need for a CAP.
I had challenges working with project collaborators.
The community did not see a need or was not interested.
I was not familiar with the community issues or needs.
I was not familiar with the community culture.
I did not have time because of other responsibilities.
Other reasons (specify):

[GO TO SECTION6_1]

SECTION5_4

What area(s) of community health did or does your CAP address?

	Yes	No
Active living
Child health
Disabilities
Elder health
Health policy
Infectious disease prevention
Mental health
Nutrition
Refugee health
STI testing
Violence prevention
Other (specify):

SECTION5_5

Did you successfully complete this CAP?

• Completed

• Ongoing: Moving forward with CAP activities [GO TO SECTION5_8]

• Stopped unexpectedly: CAP implementation was delayed [GO TO SECTION5_7]

SECTION5_6

How long did it take you to complete the CAP from planning to completion? [GO TO SECTION5_8]

___ (Years) ___ (Months)

SECTION5_7a-7f

To what extent do you agree or disagree that the following statements explain why your CAP was delayed?

	Strongly agree	Agree	Neither agree or disagree	Disagree	Strongly disagree
There was not enough technical support from the Master Trainers and/or WHLI.
I had challenges working with project collaborators.
The community did not see a need or was not interested.
There was not enough funding provided by my supervisor or organization to support a CAP.
There was change in funding situation.
I did not have time because of other responsibilities

SECTION5_8

Which of the following activities did/does your CAP involve?

	Yes	No
Repeated or ongoing community health education classes
One-time community forum/workshop
Community outreach
Community assessment
Ongoing support group
OWH Training
Other (specify):

SECTION5_9a-9f

To what extent do you agree or disagree that your CAP has resulted in the following changes in your community?

	Strongly agree	Agree	Neither agree or disagree	Disagree	Strongly disagree
Increased the community’s access to health information.
Increased the community’s access to screening and health care.
Empowered community members to improve their health.
Altered community members’ orientation/attitude toward their health.
Altered community members’ health behaviors.
Created a change in community health policy

SECTION5_10a-10m

To what extent do you agree or disagree with the following statements?

	Strongly agree	Agree	Neither agree or disagree	Disagree	Strongly disagree
The CAP requirements from the training were clear.
The CAP guidelines/ instructions were well-communicated.
I had time constraints because of other responsibilities.
A Master Trainer provided sufficient support for the CAP (e.g., to follow up on my progress and/or to answer my questions).
The training provided sufficient ground for me to develop a CAP.
I had organizational buy-in from my employer/supervisor on the CAP.
I had challenges working with project collaborators.
There was available funding from my organization to develop and implement the CAP.
I had existing relationships with partnering agencies.
The community did not see a need or was not interested in the topic.
I had sufficient community partner resources, donations, and/or space.
I was able to form a committee.
I had a lot of experience with the topic or approach addressed in the CAP.

SECTION 6: Reflection on the WHLI Training

The next set of questions asks about your experience with the Women’s Health Leadership Institute (WHLI) training. Please answer the questions to the best of your ability.

SECTION6_1

How would you rate the overall quality of the WHLI training?

• Very satisfied

• Satisfied

• Neutral

• Dissatisfied

• Very dissatisfied

SECTION6_2a-2i

To what extent do you agree or disagree with the following statements about the WHLI training?

	Strongly agree	Agree	Neither agree or disagree	Disagree	Strongly disagree
The training objectives were clear.
The training activities were engaging.
The training materials were hands-on.
The training materials provided were sufficient.
The pace of the training was appropriate.
The content was relevant to my work.
The training was relevant to community health work.
The training was well-organized.
The training met my expectations.

SECTION6_3

How many Master Trainers did you have during the WHLI training?

• 1

• 2

• 3

• 4 or more

• Don’t Know [GO TO SECTION6_5a-5j]

SECTION6_4a-4j

[Load the table up to three times based on the answer to the previous question.]

Thinking specifically about Master Trainer [IF SECTION6_3=1 THEN DISPLAY “1”; IF SECTION6_3=2 THEN DISPLAY “2”; IF SECTION6_3=3 THEN DISPLAY “3”], to what extent do you agree or disagree with the following statements?

	Strongly agree	Agree	Neither agree or disagree	Disagree	Strongly disagree
The Master Trainer was well-prepared.
The Master Trainer was knowledgeable about the subject matter.
The Master Trainer could explain a CAP and give examples.
The Master Trainer engaged CHWs.
The Master Trainer was receptive to participant comments and questions.
The Master Trainer was passionate about working with CHWs and communities.
The Master Trainer had good communication skills.
The Master Trainer had good listening skills.
The Master Trainer managed time well.
The Master Trainer related personal experiences pertaining to the leadership training event (e.g., gave personal examples, had experience/knowledge with topics, etc.)

[GO TO SECTION6_6a-6i]

SECTION6_5a-5j

To what extent do you agree or disagree with the following statements about the WHLI Master Trainers?

	Strongly agree	Agree	Neither agree or disagree	Disagree	Strongly disagree
The Master Trainers were well-prepared.
The Master Trainers were knowledgeable about the subject matter.
The Master Trainers could explain a CAP and give examples.
The Master Trainers engaged CHWs.
The Master Trainers were receptive to participant comments and questions.
The Master Trainers were passionate about working with CHWs and communities.
The Master Trainers had good communication skills.
The Master Trainers had good listening skills.
The Master Trainers managed time well.
The Master Trainers related personal experiences pertaining to the leadership training event (e.g., gave personal examples, had experience/knowledge with topics, etc.)

SECTION6_6a-6i

To what extent do you agree or disagree that the following skills taught at the WHLI training were useful to your leadership activities or CAP development?

	Training did not address issue	Strongly agree	Agree	Neither agree or disagree	Disagree	Strongly disagree
Conducting community mapping
Evaluating outcomes
Getting community buy-in
Developing a local resource/contact list
Developing a logic model
Partnering with community agencies
Presenting information
Conducting a strengths, weaknesses, opportunities, and threats (SWOT) analysis
Conducting a vision and mission analysis

SECTION6_7a-7m

To what extent do you agree or disagree that the following skills or resources would have helped you better incorporate leadership into your work?

	Strongly agree	Agree	Neither agree or disagree	Disagree	Strongly disagree
Additional training on content knowledge about policymaking
Additional training on content knowledge about specific women’s health issues
Additional training on how to identify funding sources
Additional funding provided by WHLI
Additional training on grant writing
In-person meetups with Master Trainers
Locally-provided training
Ongoing training
Additional technical support from Master Trainers and/or WHLI
Webinars following the workshop
Additional training focusing on advocacy skills
More one-on-one trainings focusing on the particular issues in the community
Opportunities to network with other CHWs from the training who are working on similar issues (work groups)

SECTION6_8

Do you have other suggestions for improving the WHLI training? (open-ended)

SECTION 7: Demographics

The last set of questions are to help us get to know you better. Please answer the questions to the best of your ability.

SECTION7_1

What is your age?

• 18 to 24 years

• 25 to 34 years

• 35 to 44 years

• 45 to 54 years

• 55 to 64 years

• Age 65 or older

SECTION7_2

What is your gender?

• Female

• Male

SECTION7_3

Are you Hispanic or Latino?

• No

• Yes

SECTION7_4

How would you best describe your race? Check ALL that apply.

• White

• Black or African American

• Asian

• Native Hawaiian or other Pacific Islander

• American Indian or Alaska Native

• Other (specify): _____________________

SECTION7_5

What is the highest level of education you have completed?

• Less than high school

• High school graduate / GED

• Some college, no degree

• Associate's degree

• Bachelor's degree

• Graduate or professional degree

END OF SURVEY

NOCONSENT_EXIT

Thank you for your time, but unfortunately you are not able to proceed with the survey without consenting to this research project.

[If the survey is terminated]

INELIG_EXIT

Thank you for your time, but unfortunately you do not qualify for this survey.

[If the pre-loaded profile indicates a completed CAP (P_CAP=1)]

EXIT_CAP

Thank you for taking the time to complete our survey. We truly value the information you have provided. To receive your $20 Amazon gift card for completing the survey, please enter your email address:

_____________________________________

In addition, based on your responses, we will contact you about scheduling a phone interview to further discuss your participation in the Women’s Health Leadership Institute. You will receive an additional $20 Amazon gift card for your time.

To make sure we have accurate information on file, please enter your full name and telephone number:

Name: _____________________________________

Telephone Number:

In the meantime, if you have any questions about the study or your responses, please contact NORC at [email protected] or XXX-XXX-XXXX.

[If the pre-loaded profile does not indicate a completed CAP (P_CAP=0)]

EXIT_NOCAP

Thank you for taking the time to complete our survey. We truly value the information you have provided. To receive your $20 gift card for completing the survey, please enter your email address:

_____________________________________

In addition, based on your responses, we may contact you about scheduling a phone interview to further discuss your participation in the Women’s Health Leadership Institute. You will receive an additional $20 Amazon gift card for your time.

To make sure we have accurate information on file, please enter your full name and telephone number:

Name: _____________________________________

Telephone Number:

In the meantime, if you have any questions about the study or your responses, please contact NORC at [email protected] or XXX-XXX-XXXX.

WEB_EXIT

[GO TO THIS SCREEN IF RESPONDENT CLICKS “SAVE AND EXIT” BUTTON AT ANY POINT IN THE SURVEY]

You have exited the WHLI Survey.

If you exited by mistake, click on this link to continue the survey where you left off. If you would like to continue at a different time, please use the link you received in the email. If you received a letter or phone call, please go to WHLIsurvey.norc.org using your unique survey PIN.

X_OUT

[Displayed as a pop-up if respondEnt attempts to close the survey browser window]

Please exit the WHLI Survey using the “Save and Exit” button. This will save your progress in the survey and ensure that you can continue where you left off at a more convenient time.

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