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 

center, library)

B Mailing

C Friend or relative

D Another agency

E Website

F Previous presentation

G TV, radio, or newspaper

H Flyer

I Other (please specify_______________

For questions 2 – 6, mark how much you agree or 

disagree with the following statement(s):

Strongly 

Agree Agree

Neither 

Agree nor 

Disagree

Disagree Strongly 

Disagree

2. It was easy to find the details of the presentation, 

such as date, time, location, and topic.

A B C D E

3. This presentation provided me with useful 

information.

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

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. Location:

Time: Date: 

Name of Presenter: ___________________________________ Address: 

Presented by: SHIP SMP Both 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

B Asian

C Black or African American

D Hispanic or Latino

E Native Hawaiian or Other Pacific Islander

F White

G Prefer not to answer

2. Which of the following best represents how you think of yourself? [Select ONE]: 

A Lesbian or gay 

B Straight, that is, not gay or lesbian 

C Bisexual 

D I use a different term ________________________________

E Don’t know

F 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.