0990-0407Appendix D - TCH Follow-Up Survey (Sample)(12.2.15)

Appendix D
Think Cultural Health (TCH) Follow-up Survey

Form Approved
OMB No. 0990-0407
Exp. Date XX/XX/20XX

Strongly
Agree

Agree

Neither
Agree
Nor
Disagree

Disagree

Strongly
Disagree

1. In the past six months, I have applied the
information in Unit _ to the work that I
do.
2. My attitude about {Unit topic} has
improved because I completed Unit _.
3. Completing Unit _ has helped me {Unit
skill}.
4. In the past six months, I have looked at
the information in Unit _ again to help
me in my daily work.
5. Taking a training in {Unit topic} was easy
to do online.
6. I would take another training related to
my work online.
7. I think other {target audience} would
benefit from Unit _.
8. Do you have more comments about Unit _? If so, please explain them here.

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 0990-0407. 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

Appendix D
Think Cultural Health (TCH) Follow-up Survey
12 Month Follow Up Interview of A Subset of Users That Complete At Least One Unit
1.
2.
3.
4.
5.
6.
7.
8.
9.

How have you applied the information in Unit _ to the work that you do?
What additional information would make Unit _ more applicable to the work you do?
How has your attitude about {Unit topic*} changed because you completed Unit _?
How has completing Unit _ changed the way you {Unit skill**}?
In the past six months, what information in Unit _ have you looked at again to help you in your
daily work?
How was the information provided in Unit _ relevant to your culture?
What was it like taking a training on {Unit topic*} online?
What types promotores de salud do you think would benefit from Unit _?
What additional comments do you have about Unit _?

*Unit Topics:
Unit A: “understanding healthy choices”
Unit B: “helping people make healthy choices”
Unit C: “understanding community change”
Unit D: “helping people make community changes”
**Unit Skills:
Unit A: “talk with someone about healthy choices”
Unit B: “teach people in your community to take action toward health”
Unit C: “make community changes”
Unit D: “empower people to make community changes”