Developing a Self-Assessment Toolfor Culturally - Office of Minority ...
Developing a Self-Assessment Toolfor Culturally - Office of Minority ...
Developing a Self-Assessment Toolfor Culturally - Office of Minority ...
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Organization Code:Questionnaire:Appendix F______________________________________PILOT TEST RESPONSE FORMInstructions:1. Please use this form to record your responses to the Pilot Test Questionnaire Package.If different staff members share the effort <strong>of</strong> completing the questionnaire, pleaseallow each individual to complete this form for the appropriate section(s). Forexample, if one staff member completes sections A through C <strong>of</strong> the questionnaireand another staff member completes section D, each staff member should record theirresponses in the table on page 2 <strong>of</strong> this form only for the section(s) that correspond tothe section(s) they completed in the questionnaire.2. On page 2, rate the utility <strong>of</strong> each component (cover letter; questionnaire cover sheet;and questionnaire sections A-D) based on the categories provided and the followingrating scale: (1 = very appropriate); (2 = appropriate); (3 = somewhat appropriate);and (4 = not appropriate). In using the rating scale, consider the level <strong>of</strong>appropriateness for presenting each component to someone in a similar staff positionto yours. Also, if you rate a particular component category as “3" (somewhatappropriate) or “4" (not appropriate), please let us know why, or give suggestions forchange, by commenting in the box provided on page 3 <strong>of</strong> this form.Please evaluate each questionnaire section as a whole, but feel free to provide writtencomments in the box on page 3 if there are particular items <strong>of</strong> concern within asection. If you provide written comments on a particular question or item, pleaseindicate the questionnaire section and question number you are referring to.3. In addition, your general comments and suggestions about the design or topicalcontent <strong>of</strong> the questionnaire, or specific questions within, are greatly appreciated.4. Finally, please return this Pilot Test Respondent Evaluation Form with yourcompleted questionnaire.Thank you.COSMOS Corporation, December 2003 F-1