Self-directed Violence Surveillance: Uniform Definitions and Recommended Data Elements - Satisfaction and Usability Assessment Survey

Form Approved
OMB No. 0920-0847
Exp. Date 02/28/2013

Public reporting burden of this collection of information is estimated to be 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30033; Attn: PRA (0920-0847).

Please answer all questions as indicated.

1

1. How many years experience do you have with violence prevention?

I have no experience with violence prevention

Less than a year

1 to 5 years

6 to 10 years

11 or more years

2

What area of violence prevention do you have experience with (choose all that apply)?

Child maltreatment

Intimate partner violence

Sexual violence

Suicide

Youth violence

Other, please specify

3

Which of the following agencies/categories best describes where you work?

Federal government

State government

State level, non-governmental organization

Local, county, or tribal government

University or college

School or school system

Hospital or healthcare system

Faith-based organization

Media, marketing, or public relations

Community-based organization

Advocacy organization

Other, please specify

4

What is your current job title? Please specify.

5

This product is useful to me in my work.

Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree	Not Applicable
*This product is useful to me in my work. Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree	Not Applicable

6

This product has changed (will change) the way I work to prevent violence.

Strongly disagree	Disagree	Neutral	Agree	Strongly agree	Not applicable
*This product has changed (will change) the way I work to prevent violence. Strongly disagree	Disagree	Neutral	Agree	Strongly agree	Not applicable

7

This product has increased my knowledge of suicide.

Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
*This product has increased my knowledge of suicide. Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree

8

This product is easy to understand.

Strongly disagree	Disagree	Neutral	Agree	Strongly agree
* This product is easy to understand. Strongly disagree	Disagree	Neutral	Agree	Strongly agree

9

Would you recommend this product to others?

Would you recommend this product to others? Yes

No

I’m not sure

10

This product has led me to make professional choices and decisions that I would not have made otherwise.

Never	Rarely	Sometimes	Often	Very often	Not applicable
*This product has led me to make professional choices and decisions that I would not have made otherwise. Never	Rarely	Sometimes	Often	Very often	Not applicable

11

How could the product be improved?