CECS: Consultant Site Evaluation Survey



Today's Date: 02/09/2010 Thank you for participating in this confidential survey. Please complete a new survey for each CTSA site you visited.

1.	Consultant Name:
2.	Consultant Phone #:
3.	Consultant E-mail:


4.	Please provide the name of the CTSA site and the date visited:
	Site visited:
	Date visited:

5.	What was the objective of your visit?

6.	How would you rate the visit?
	3=very productive 2=somewhat productive 1=minimally productive Explain your response:

7.	After the initial visit: a. did you make follow-up contact with the CTSA Site? Yes No b. did the CTSA Site contact you for more assistance? Yes No

8.	How confident are you that this site will be able to develop an action plan based on your recommendations? 3=very confident 2=somewhat confident 1=minimally confident Explain your response:

9.	How confident are you that this site will be able to implement this action plan? 3=very confident 2=somewhat confident 1=minimally confident Explain your response: