Form TA Evaluation Form TA Evaluation Form TA Evaluation Form

OMB No. 0930–0197

Expiration Date: 01/31/2011

Attachment A

Recovery to Practice (RTP) Resource Center

Public Burden Statement: 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. The OMB control number for this project is 0930–0197. Public reporting burden for this collection of information is estimated to average 0.083 hours per respondent per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, One Choke Cherry Road, Room 7–1044, Rockville, MD 20857.

Technical Assistance Evaluation Form

Please evaluate on a scale of 1 to 5 (with 1 being the lowest and 5 the highest) by circling a number to the right of each question below.

Brief description of TA and how it will be used: _____________________________

______________________________________________________________________

______________________________________________________________________

Evaluation of the Overall Technical Assistance

1. How responsive was the TA to your stated need? 1 2 3 4 5

2. How useful was the TA in providing you with 1 2 3 4 5

new information?

3. To what extent did you connect to a new resource? 1 2 3 4 5

In what way(s) did the TA benefit you or help meet your goals?

In what way(s), if any, would the TA have been more helpful?

Evaluation of Consultant or Staff Providing TA (Name: _____________________)

4. Knowledgeable in subject area 1 2 3 4 5

5. Listened well and communicated clearly 1 2 3 4 5

6. Provided useful recommendations/insights 1 2 3 4 5

Please email your completed form to: [email protected] Thank you!

1

Development Services Group, Inc.  7315 Wisconsin Avenue  Suite 800-E  Bethesda, MD 20814 