PRIMARY CARE RESEARCH LINKAGE QUASI-MODIFIED CAPACITY

ASSESSMENT EVALUATION TOOL

PART 1: Individual Capacity Assessment Evaluation
GENERAL INSTRUCTIONS
Greetings! You are requested to provide information as a researcher in the residency training program of family and community medicine on the spaces allowed for
each item. Only the research team #smallville, will have access to sensitive data. Before accomplishing this form, please read the accompanying Quality Control
Procedures for Data Collection. Answer in blue or black ink. Please do not leave any space blank. For those items that do not apply to you, place ‘N/A’ (which
stands for Not Applicable). Please write legibly and avoid erasures. If you have any questions, you may contact DR. MARVIN MUNAR of the Ilocos Training and
Regional Medical Center, the lead investigator for this research at 0916-286-3343.

A. BACKGROUND INFORMATION OF RESEARCHER

Please fill in all required information. Do not leave Landline/Mobile Phone Number (3A4) and E-mail Address (3A5) blank. For items that do not apply to you or to
your consortium, please put N/A.

1A1 Name of Researcher

(Last, First, Middle Initial)

1A2 Date of Birth 1A3 Sex Male

Please check (√) the corresponding box of your answer.
m m d d y y y y Female

1A4 Landline/Mobile Phone 1A5 E-mail Address

Number
Include Area Code

1A6 Primary Institutional

Affiliation

1A7 Address of Primary

Institutional Affiliation
(Street, City/Province, Region)
 1A8 Which region does your Region I Region IV-A Region VI Region IX Region XII CAR
institution belong to?
Please check (√) the box of Region II Region IV-B Region VII Region X Region XIII NCR
your answer.
Region III Region V Region VIII Region XI ARMM

1A9 Other Institutional

Affiliation (1)
1A10 Other Institutional
Affiliation (2)
1A11 Have you ever done health research in your professional career? Yes (Continue to Section B)
Please check (√) the corresponding box of your answer.
No (End of Questionnaire)
1A12 Date Form was
Accomplished
m m d d y y y y

B. EDUCATIONAL ATTAINMENT
Indicate all the degree(s) that you have completed as of December 31, 2018 by checking (√) all the boxes that apply to you. Specify the field of specialization, the
school where you obtained the degree, and the year you graduated in the respective columns. Allot one space for each answer in Column 2. For items that do not
apply to you, please put ‘N/A’.

1B1 Doctorate 1B7 1B13 1B19

y y y y
 1B2 Masters (1) 1B8 1B14 1B20
y y y y

1B3 Masters (2) 1B9 1B15 1B21

y y y y

1B4 Doctor of 1B10 1B16 1B22

Medicine
y y y y

1B5 Baccalaureate 1B11 1B17 1B23

y y y y

1B6 Others 1B12 1B18 1B24

(e.g. postgraduate)
Diploma, y y y y
Postgraduate
Certificate, law
Degree, etc.)

C. TRAINING ON BASIC OR ADVANCED RESEARCH METHODS IN 2018

Please provide information about the research-related trainings you have attended in 2018. Specify the details of each training in the table provided. For items that
do not apply to you, please put ‘N/A’.
 1C1 Have you attended any research-related training in 2015? Yes (Continue to 1C2)
Please check (√) the corresponding box of your answer.
No (Proceed to Section D)

If you answered ‘yes’ to 1C1, please provide details on the training(s) you participated in 2018 starting with the most recent training first. Allot one space for each
training. For items that do not apply to your institution, please put ‘N/A’.

Name of Training Date Started Date Completed Sponsor/s

(Column 1) (Column 2) (Column 3) (Column 4)

1C2 1C12 1C22 1C32

m m y y y y m m y y y y

1C3 1C13 1C23 1C33

m m y y y y m m y y y y

1C4 1C14 1C24 1C34

m m y y y y m m y y y y

1C5 1C15 1C25 1C35

 m m y y y y m m y y y y

1C6 1C16 1C26 1C36

m m y y y y m m y y y y

1C7 1C17 1C27 1C37

m m y y y y m m y y y y

1C8 1C18 1C28 1C38

m m y y y y m m y y y y

1C9 1C19 1C29 1C39

m m y y y y m m y y y y

1C10 1C20 1C30 1C40

 m m y y y y m m y y y y

1C11 1C21 1C31 1C41

m m y y y y m m y y y y

D. PROFESSIONAL DEVELOPMENT
Please provide information regarding your receipt of scholarship for graduate and/or postgraduate degree(s) and sponsorship for research-related training(s) from
PCHRD, CHED/SUCs. DOH and/or UPM. Specify your work in 2018 and provide pertinent details about your health research practice. For items that do not apply
to you, please put ‘N/A’.

1D1 Have you ever received any scholarship for graduate and/or postgraduate degree(s) from PCHRD, CHED/SUCs, DOH and/or UPM? Yes
Please check (√) the corresponding box of your answer.
No

1D2 Have you ever received any sponsorship for research-related training(s) from PCHRD, CHED/SUCs, DOH and/or UPM? Yes
Please check (√) the corresponding box of your answer.
No

1D3 What was your work in 2018? Health Researcher

Please check (√) all the boxes that apply to you.
If you checked ‘Health Researcher’, continue to 3D4. Health Research Manager (i.e. Project Officer)
If not, proceed to Section E.
Teacher (Without research)
 Administrator
Other
Please specify

1D4 If you checked ‘Health Researcher’ in 3D3, was any of your health/health-related research in 2018 aligned with the National Yes
Unified Health Research Agenda (NUHRA) for 2013-2017?
Please check (√) the corresponding box of your answer. No

1D5 If you checked ‘Health Researcher’ in 3D3, was any of your health/health-related research in 2018 aligned with the current approved Yes
Regional Unified Health Research Agenda (RUHRA)?
Please check (√) the corresponding box of your answer. No

1D6 If you checked ‘Health Researcher’ in 1D3, have you had any health/health-related research published, either in part or in its Not
Entirely, in any scientific journal in 2018 Applicable
Please check (√) the corresponding box of your answer.

1D7 If you checked ‘Health Researcher’ in 1D3, have you had any health/health-related research with any potential use for health policy, Yes
health plan/program?
Please check (√) the corresponding box of your answer. No

1D8 If you checked ‘Health Researcher’ in 1D3, have you had any health/health-related research translated, either in part or in its Yes
Entirely, into health policy, health plan/program in 2018?
Please check (√) the corresponding box of your answer. No

1D9 If you checked ‘Health Researcher’ in 1D3, have you had any health/health-related research with any potential commercial value? Yes
Please check (√) the corresponding box of your answer.
No

1D10 If you checked ‘Health Researcher’ in 1D3, have you had any health/health-related research translated, either in part or in its Yes
Entirely, into commercial product in 2018?
Please check (√) the corresponding box of your answer. No
E. STAKEHOLDER AWARENESS AND SATISFACTION ON RESEARCH SERVICES AT THE REGIONAL LEVEL FOR 2018
For this section, please indicate your awareness and satisfaction on your Regional Health Research and Development Consortium’s (RHRDC) services. For items
that do not apply to you, please put ‘N/A’.

1E1 Are you aware of any services of the RHRDC? Yes (Continue to 1E2)
Please check (√) the corresponding box of your answer.
No (End of Questionaire)

If you answered ‘yes’ to 1E1, please indicate which of the following RHRDC services you have availed of in 2018 by checking (√) either ‘yes’ or ‘no’ in Column 1.
For those services that you availed of, check (√) the box that represents your level of satisfaction (i.e. Very High, High, Average, Love, Very Low) for that experience
in Column 2.

Availed? If you answered ‘yes’ to Column 1, what is your level of

(Column 1) Satisfaction for the corresponding service?
(Column 2)
________________ ____________________________________________________________
Yes No Very High High Average Low Very Low

1E2 Access to research funds and grants 1E8

1E3 Access to training funds and grants (i.e. scholarships) 1E9

1E4 Access to information services (i.e. databases and 1E10

publications)
 1E5 Submission of research proposals for technical 1E11
reviews
1E6 Submission of research proposals for ethics reviews 1E12

1E7 Sponsorship of trainings regional level 1E13

If you answered at least one ‘yes’ in Column 1, please evaluate the efficiency and effectiveness of your Consortium’s administrative processes and services in 2018.
Check (√) the box that represents your assessment (i.e. Very High, High, Average, Love, Very Low) for each indicator.

If you answered at least one ‘yes’ to Column 1, what is your level of

satisfaction in terms of the following indicators?
_________________________________________________________________________________
Very High High Average Low Very Low
1E14 Response time

1E15 Quality of services

1E16 Staff behavior and attitude

1E17 If you answered at least one ‘yes’ in Column 1, what are your suggestions to improve the administrative processes and services of your
Consortium?
Please write your response in the space provided.

Thank you for accomplishing this form.