Form 1 Enrollment Form

ATTACHMENT A
CREATIVE FORCES COMMUNITY ENGAGEMENT PROGRAM
PARTICIPANT OUTCOMES SURVEY PILOT TEST INSTRUMENTS
ENROLLMENT FORM
Your Creative Forces program is part of a national pilot study of a Participant Outcomes Survey for the
Creative Forces®: NEA Military Healing Arts Network Community Arts Engagement Grant Program. The
National Endowment for the Arts and its cooperator, Mid-America Arts Alliance, are interested in
learning more about the experiences and needs of the people who participate in Creative Forces
community arts programs. The pilot data will be used to evaluate and improve the survey. We are very
interested in your experience and ideas, and we hope you will share your real thoughts.
As part of this study, data from this enrollment form will be shared with the Veritas Management Group,
a research team contracted by Mid-America Arts Alliance as part of the Creative Forces®: NEA Military
Healing Arts Network Community Arts Engagement Grant Program. You may be contacted to participate
in a pilot test of the survey. Your participation in the pilot test is entirely voluntary, and all information
you contribute will be kept fully confidential. You will not receive any compensation for completing this
form. You may decline to answer any questions you wish.
Under the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless such collection displays a valid Office of Management and Budget (OMB) control
number. The OMB control number for this survey is OMB No. XXXX-XXXX (expires XX/XX/XXXX). The time
required to provide responses to the survey questions is estimated to be approximately 6 minutes.
Please contact Debra Holden, Ph.D., of Veritas Management Group at
[email protected] if you have questions about this pilot study or the National
Endowment for the Arts at [email protected] if you have any questions regarding the estimated time
burden or any other aspect of this data collection. If you have any questions about your rights as a
participant in the study, you may contact Solutions IRB (the body that oversees our protection of study
participants) at (855) 226-4472 or [email protected].
Please tell us if we have your permission to share information from this enrollment form with the
Creative Forces research team. You can still enroll in this program without agreeing to share
information from this form. Your decision to share information will in no way impact the outcome of
any present or future grant applications, contract proposals, or cooperative agreement proposals with
the National Endowment for the Arts or Mid-America Arts Alliance.
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Yes, I grant permission for information from this enrollment form to be shared with the Creative
Forces research team.
No, I do not grant permission for information from this enrollment form to be shared with the
Creative Forces research team.

*Please feel free to print or save a copy of this form for your records.*

1. Name: _________________________________________________________________
2. Email address: ___________________________________________________________
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3. Telephone number: ________________________________
4. Which best describes you? (check all that apply)
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Service Member
o Active Duty
o National Guard
o Reserve
Veteran
o Retiree
Spouse/Partner of a Service Member or Veteran
o Active Duty Service Member
o National Guard/Reserve
o Veteran
Other Family Member of a Service Member or Veteran
o Active Duty
o National Guard/Reserve
o Veteran
Caregiver for a
o Service Member
o Veteran
Health care worker serving military-connected populations
Civilian
Other ________
Prefer not to say

5. What is your age?

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18-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+

6. Which best describes you? (check all that apply)
□ American Indian or Alaskan Native
□ Asian
□ Black or African American
□ Hispanic or Latino
□ Native Hawaiian or other Pacific Islander

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□ White
□ Other Racial/Ethnic Group
□ Prefer not to say
7. Do you identify as:
□ Female
□ Male
□ Prefer not to say

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