End of Wave 1 Feedback Survey

Form Approved OMB No. 0990-XXXX Exp. Date XX/XX/2018

Site Coordinator Feedback on the I Can Do It, You Can Do It! Program

End of Wave 1

Thank you for facilitating the I Can Do It, You Can Do It! (ICDI) program for individuals with a disability. You are receiving this questionnaire because you served as the Site Coordinator for an incentivized I Can Do It, You Can Do It! Program.

Please take a few moments to provide us with your feedback regarding technical assistance, program materials, and participation more generally, by responding to the following questions. Feedback from this survey will be kept private to the extent permitted by law. Neither your identity, nor the identity of your site, will be connected to these responses. Results will be used to guide future updates and improvements of the ICDI program. Thank you for your feedback!

Section I: General Program Information

1. What is one essential thing we could do to improve the ICDI program in the future?

2. Is there anything additional that you would like to share about your experience in the ICDI program?

Section II: Technical Assistance

3. How often throughout the program did you proactively reach out for information and support from your Technical Assistance team member?

• Never

• 1-4 times throughout the program

• Weekly

• Multiple times a week

• Daily

4. How often throughout the program did your Technical Assistance team member proactively reach out to you?

• Never

• 1-4 times throughout the program

• Weekly

• Multiple times a week

• Daily

5. How often throughout the program did you receive the information and support you needed from your Technical Assistance team member?

• Always

• Most of the time

• About half the time

• Almost never

• Never

6. How would you rate the Technical Assistance team’s level of support throughout the ICDI Program?

• Excellent

• Very good

• Good

• Fair

• Poor

7. What additional support from the Technical Assistance team would have been helpful?

Section III: Materials and Resources

8. Overall, how do you rate the ICDI materials?

• Excellent

• Very good

• Good

• Fair

• Poor

9. The ICDI materials assisted me in setting up a new ICDI Program.

• Strongly Agree

• Agree

• Neither Agree nor Disagree

• Disagree

• Strongly Disagree

• Not applicable, I already had an ICDI program up and running

10. The ICDI materials assisted me in including individuals with a disability in an existing program that did not include individuals with a disability before.

• Strongly Agree

• Agree

• Neither Agree or Disagree

• Disagree

• Strongly Disagree

• Not applicable

11. Using a scale of 1 = Not Useful At All to 5 = Very Useful, please rate the usefulness of ICDI materials to support the following components of your ICDI program.

	Not Useful At All 1	Not Very Useful 2	Neutral 3	Somewhat Useful 4	Very Useful 5	N/A – I did not use or review this item
Program Setup and Implementation	○	○	○	○	○	○
Marketing	○	○	○	○	○	○
Health and Goal Setting	○	○	○	○	○	○
Training	○	○	○	○	○	○

12. Are there materials you wish had been provided?

The following questions will ask about specific ICDI materials that you may or may not have used in your program.

13. The Checklist: Getting Started in ICDI document was clear in outlining the steps I needed to take to establish my ICDI program.

• Strongly Agree

• Agree

• Neither Agree or Disagree

• Disagree

• Strongly Disagree

• Not applicable

16a. Please provide any comments you have about the Checklist: Getting Started in ICDI document.

14. The Orientation for ICDI Site Coordinators presentation adequately informed me about my role and expectations as a coordinator of an ICDI incentivized site.

• Strongly Agree

• Agree

• Neither Agree or Disagree

• Disagree

• Strongly Disagree

• Not applicable

17a. Please provide any comments you have about the Orientation for ICDI Site Coordinators presentation.

15. The ICDI Program Introduction presentation was adequate for me to inform mentors about the ICDI program.

• Strongly Agree

• Agree

• Neither Agree or Disagree

• Disagree

• Strongly Disagree

• Not applicable

18a. Please provide any comments you have about the ICDI Program Introduction presentation for Mentors. If presentation was inadequate, please identify what would have helped the presentation meet your needs.

16. The ICDI Mentor Training presentation was adequate for me to inform mentors about their responsibilities and teach them the skills necessary to implement the program.

• Strongly Agree

• Agree

• Neither Agree or Disagree

• Disagree

• Strongly Disagree

• Not applicable

19a. Please provide any comments you have about the ICDI Mentor Training presentation. If presentation was inadequate, please identify what would have helped the presentation meet your needs.

17. The Goal Setting Handbook supported the integration of weekly goal-setting in my ICDI program.

• Strongly Agree

• Agree

• Neither Agree or Disagree

• Disagree

• Strongly Disagree

• Not applicable

20a. Please provide any comments you have about the Goal Setting Handbook.

18. The PALA+ Goal Resources provide informative, easy to understand physical activity and healthy eating goal information.

• Strongly Agree

• Agree

• Neither Agree or Disagree

• Disagree

• Strongly Disagree

• Not applicable

21a. Please provide any comments you have about the PALA+ Goal Resources.

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-XXXX. The time required to complete this information collection is estimated to average 11 minutes per response. 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.