Potential Participant Survey OMB Control Number: 0970-0531
Expiration Date: 7/31/2022
A research organization named Mathematica is working with Viability to improve the MOMS Partnership program. We are going to ask you some questions about what you just heard about the program. The answers to your questions will help improve how MOMS Partnership is described. It should take about 5 minutes to complete this survey.
You can decline to complete the survey or leave any questions blank. Your individual response will not be associated with your name. All responses will be combined; no one outside the research team will know how you responded.
The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to gather information for the purpose of rapid-cycle learning activities to strengthen programs. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: 0970-0531, Exp: 07/31/2022. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Sheena McConnell; [email protected]
Based on what you heard today, do you think you might be eligible for MOMS Partnership?
Yes
No
If yes, move to question 2. If no, end survey.
To what extent do you agree or disagree with the following statements?
Statement |
Strongly disagree |
Disagree |
Agree |
Strongly agree |
Not sure |
|
1 |
2 |
3 |
4 |
5 |
|
1 |
2 |
3 |
4 |
5 |
|
1 |
2 |
3 |
4 |
5 |
|
1 |
2 |
3 |
4 |
5 |
|
1 |
2 |
3 |
4 |
5 |
|
1 |
2 |
3 |
4 |
5 |
What might make it difficult for you to attend an enrollment appointment? Choose all that apply:
Lack of child care
Other family responsibilities
Lack of transportation
Employment or education commitments
Other, specify.
How likely are you to follow through and enroll in MOMS Partnership?
Very likely
Likely
Somewhat likely
Not at all likely
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | NS2G Staff Survey |
Author | MATHEMATICA |
File Modified | 0000-00-00 |
File Created | 2024-07-24 |