Group Outreach and Education Survey

Group Outreach and Education Survey
OMB CONTROL NUMBER: 0985-0056

The following questions ask about the presentation you recently attended. Please answer all of the questions
and leave the comment card with the presenter when you finish. Thank you!
1. How did you learn about today’s presentation? (mark all that apply)
A Event location announcement (e.g., senior
E Website
center, library)
F Previous presentation
B Mailing
G TV, radio, or newspaper
C Friend or relative
H Flyer
D Another agency
I Other (please specify_______________

For questions 2 – 6, mark how much you agree or
disagree with the following statement(s):

Neither
Strongly
Agree nor Disagree
Disagree
Disagree

Strongly
Agree

Agree

A

B

C

D

E

A

B

C

D

E

4. Overall, I am satisfied with the presentation today.

A

B

C

D

E

5. I would contact the presenter for help or
information.

A

B

C

D

E

6. I would recommend this presentation to others.

A

B

C

D

E

2. It was easy to find the details of the presentation,
such as date, time, location, and topic.
3. This presentation provided me with useful
information.

7. Based on what you learned today, do you plan to take any specific actions?
A Yes (please specify below).
__________________________________________________________________________________
B No.
C Don’t know/not sure.
8. What could we do to improve the information or service(s) provided to you today?

Presentation information to be completed by program official.
Time:

Name of Presenter: ___________________________________
Presented by:

Location:

Date:
SHIP

SMP

Both

Address:
Office of Management and Budget (OMB) Survey Expiration Date: xxxx, xxxx

Survey continues on the next page

Demographic Questions
Thank you for answering our questions about your experience with the SHIP/SMP. We have four additional demographic
questions to get a better sense of who we’re serving. Your responses will not be shared individually. They will be
reported in a summary with many other responses/answers. With each question, you have an option not to answer.
1. Which of the following race(s) best represent you? [Select ALL that apply]:
A American Indian or Alaskan Native
E Native Hawaiian or Other Pacific Islander
B Asian
F White
C Black or African American
G Prefer not to answer
D Hispanic or Latino
2. Which of the following best represents how you think of yourself? [Select ONE]:
A
B
C
D
E
F

Lesbian or gay
Straight, that is, not gay or lesbian
Bisexual
I use a different term ________________________________
Don’t know
Prefer not to answer

3. What sex were you assigned at birth, on your original birth certificate?
A Female
B Male
C Don’t know
D Prefer not to answer
4. What is your current gender? [Select ONE]
A Female
B Male
C Transgender
D I use a different term ________________________________
E Don’t know
F Prefer not to answer
Public Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such
collection displays a valid OMB control number (OMB 0985-0056). Public reporting burden for this collection of information is
estimated to average five minutes per response, including time for gathering and maintaining the data needed and completing and
reviewing the collection of information. The obligation to respond to this collection is voluntary.