Mentor Feedback Survey

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

I Can Do It, You Can Do It! Mentor Program Feedback Survey

Instructions:

Thank you for your involvement with the I Can Do It, You Can Do It! Program. This survey will collect feedback about your experience from start to finish with the ICDI Program. Remember, as discussed in the consent form, we are not asking for any names. All of your information will be kept private to the extent permitted by law. Individual answers will be added to those of everyone else, so your information and answers are not identifiable. This survey will take about 11 minutes to complete. The information gathered today will provide us with information that will be used to improve our programs in the future.

Section I: Mentor Personal Information:

In this section, we ask general information about you.

1. What is your age? ________

2. What is your gender?

• Male

• Female

3. What is your race or ethnicity?

• American Indian or Alaska Native

• Asian

• Black or African-American

• Hispanic or Latino

• Native Hawaiian or Pacific Islander

• White

4. Prior to this Wave, had you ever served as an ICDI Mentor?

• Yes

• No, this was my first time as an ICDI Mentor

5. A disability is any condition of the body or mind that makes it more difficult to do certain activities where you live, learn, work, and play. Do you identify as an individual with a disability?

• Yes (Please answer question 5a)

• No (Please skip ahead to question 6)

5a. If you identify as an individual with a disability, please select all that apply.

• Hearing difficulty (e.g., deaf or having serious difficulty hearing)

• Vision difficulty (e.g., blind or having serious difficulty seeing, even when wearing glasses)

• Cognitive difficulty (e.g., because of a physical, mental, or emotional problem, having difficulty remembering, concentrating, or making decisions)

• Ambulatory difficulty (e.g., having serious difficulty walking or climbing stairs)

• Self-care difficulty (e.g., having difficulty bathing, dressing, eating, or toileting)

• Independent living difficulty (e.g., because of a physical, mental, or emotional problem, having difficulty doing errands alone, such a visiting a doctor’s office or shopping)

Section II: Your ICDI Program Site

In this section, we ask about the program site where you were a Mentor.

6. Select the name of your ICDI program site: (dropdown menu)

7. Did your ICDI program site provide you with mentoring training?

• Yes (Please answer questions 7a, 7b & 7c)

• No (Please skip ahead to question 8)

7a. How would you describe the mentoring training that was provided by your ICDI program site?

• Excellent

• Very Good

• Good

• Fair

• Poor

7b. The ICDI Mentor Training presentation fulfilled the intended purpose to educate and empower mentors to meet the needs of individuals with disabilities:

• Strongly Agree

• Agree

• Neither Agree nor Disagree

• Disagree

• Strongly Disagree

7c. How would you improve the mentor training that was provided by ICDI program site? Are there things you wish were included or discussed?

8. How often did you receive the information and support you needed from the ICDI program site?

• Always

• Most of the time

• About half the time

• Almost never

• Never

9. How would you rate your ICDI program site’s level of mentor support throughout the ICDI Program?

• Excellent

• Very good

• Good

• Fair

• Poor

10. What additional support from the ICDI program site would have been helpful?

11. How many mentees did you mentor during the ICDI Program?

    • 1 mentee

    • 2 mentees

    • 3 mentees

    • 4 or more mentees

12. How often did you meet in-person with your mentee throughout the program?

• More than once each day

• Once a day

• 4-6 times a week

• 2-3 times a week

• Once a week

• Less than once a week

13. How often did you communicate with your mentee (e.g., phone, email, social media)?

• More than once each day

• Once a day

• 4-6 times each week

• 2-3 times a week

• Once a week

• Less than once a week

14. What kind of activities did you do with your mentee in the program? (Please select all that apply)

• We played sports together (e.g., basketball, tennis)

• We exercised together (e.g., in a gym, fitness center, outside)

• We participated in non-sports activities (e.g., tag, Red Rover)

• We participated in indoor activities ( e.g., dancing, mall walking)

• We did outdoor activities together (e.g., biking, hiking, playground)

• We discussed good nutritional practices

• We participated in healthy cooking demonstrations

• We ate a meal or snack together

• We socialized with one another

• I helped my mentee find new recreational activities and resources

• Other, please specify:

15. What was the biggest challenge(s) in working with your mentee during the program? (Please select all that apply)

• Mentee attendance

• Mentee transportation

• Mentor (my) transportation

• Issues related to the mentee’s disability

• Issues related to communication with the mentee

• Other, please specify:

Section III: ICDI Resources

In this section, we ask about ICDI Resources, including the Goal-setting Handbook and the PALA+ Goals.

16. The Goal-setting Handbook helped me set weekly goals with my mentee.

• Strongly Agree

• Agree

• Neither Agree or Disagree

• Disagree

• Strongly Disagree

• Not applicable

17. The Goal-setting Handbook was easy for me to use.

• Strongly Agree

• Agree

• Neither Agree or Disagree

• Disagree

• Strongly Disagree

• Not applicable

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

19. The PALA+ Goal Resources supported goal-setting with my mentee.

• Strongly Agree

• Agree

• Neither Agree or Disagree

• Disagree

• Strongly Disagree

• Not applicable

19a. Please provide any comments you have about the PALA+ Goal Resources.

20. What other resources did you provide to your mentees related to physical activity and healthy eating?

21. What would you like to see added to the program materials and health resources? What was missing?

Section IV: General Information

In this section, we ask about your experience with the ICDI program.

22. Why did you decide to participate in this ICDI Program? (Please select all that apply)

• As someone with a disability I thought I could be a role model and help mentor someone else with a disability to lead a healthy lifestyle.

• I think physical activity is critical and I wanted to support a program with this focus.

• In addition to motivating the mentee to increase his or her physical activity, I thought this might motivate me to increase my physical activity.

• I know the organization that sponsors the program and wanted to support their work.

• I thought it sounded like fun to be involved.

• It supports my career goals.

• My involvement was required by my employer.

• I earned course credits and/or volunteer service hours.

• Other, please specify:

23. If the opportunity is available, would you like to continue being a mentor in an ICDI Program?

• Yes

• No

24. Would you recommend being a mentor in an ICDI Program to your friends, colleagues, or family members?

• Yes

• No

25. Which one of the following best describes your experience with the ICDI Program?

• I liked it a lot.

• I mostly liked it.

• I did not like it or dislike it.

• I mostly disliked it.

• I disliked it a lot.

26. What do you think could be done to improve this ICDI Program? (Please select all that apply)

• There should be more guidance about what to do with mentees.

• There should be more materials available about the benefits of physical activity.

• There should be more examples of how to be active.

• There should be more materials available about making good nutritional choices and eating healthy.

• There should be opportunities to connect with other mentors.

• There should be activities where you can socialize and be active with other mentor/mentee pairs.

• Other, please specify:

27. Do you have any other comments about the ICDI Program?

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 8 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.