Peer Support and Pain Self-Management Education Program Feedback

Form Approved
OMB No. 0990-0379
Exp. Date 06/30/2020

Peer Support and Pain Self-Management Education Program Feedback
The following information is collected to help ensure the quality of future peer
support specialist coaching and chronic pain workshops.
Date:

_

Date of Birth: ____________________

Workshop Leaders/Peer Support Specialist Name: ______________________________
Did you attend peer support specialist coaching, the chronic pain workshop,
or both (please circle)?
Peer Support
Chronic Pain Workshop
Both
Please circle the number that best matches how you are feeling:
I am confident that I can manage my chronic pain.
Not at all
confident

1

2

3

4

5

6

7

8

9

10

Totally
confident

I am confident that I can manage my chronic pain without prescription
medications.
Not at all
confident

1

2

3

4

5

6

7

8

9

10

Totally
confident

How well are you able to distract yourself from your pain?
Not
at
all
well

1

2

3

4

5

6

7

8

9

10

Extremely
Well

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 20 minutes per response,
including the time to review instructions, search existing data resources, gather the data needed, to review and complete 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

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Do you have any suggestions for how the Chronic Pain workshop or peer support coaching
could be improved?

What would you tell others who might be interested in participating in the program in the
future?

1. Please indicate how much you agree or disagree with the following
statements:
a. The leaders and/or peer support specialist
made me feel welcome and valued.

b. I now have a better understanding of how to
manage the symptoms of my chronic health
condition(s).
c. I felt my opinions and contributions were
valued by the leaders and/or peer support
specialist.
d. I will use what I learned in the workshop
and/or peer support coaching in my life.

Strongly
Agree

Agree

Disagree

Strongly
Disagree

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

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THANK YOU FOR COMPLETING THE SURVEY!

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