Form End-of Email Surve End-of Email Surve End-of Email Survey

Attachment 1: End-of-Email Survey

OMB No. 0930-0197

Expiration Date: 01/31/11

Technical Assistance Partnership Feedback Survey

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 2 minutes 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, 1 Choke Cherry Road, Room 8-1099, Rockville, Maryland, 20857.

The Technical Assistance Partnership for Child and Family Mental Health (TA Partnership) values your feedback!

Help improve our services by providing anonymous feedback!

The TA Partnership is committed to providing quality and effective services and focusing on areas in need of improvement. We take pride in our work and value your feedback to ensure we maintain an excellent level of performance. Thank you for your anonymous feedback!

About the TA Service or Event

1. Which TA Partnership service/event are you sharing feedback about?¹

Community call

National affinity call

Follow-up to TA request

TA visit planning call

Early Childhood Community of Practice

Transition-Aged Youth Community of Practice

Family Involvement Community of Practice

Cultural and Linguistic Competence Community of Practice

African Heritage Learning Community

Asian American, Native Hawaiian, and Other Pacific Islander Learning Community

Latino Learning Community

LGBTQI2-S Learning Community

Fatherhood Learning Community

Other (please specify below)

2. Content/topic of service/event (select all that apply):

Governance Cultural Competence Linguistic Competence Family-Driven Care/Engagement	Youth Engagement Financing Clinical Services Social Marketing	Collaboration Evaluation Sustainability
Other (please identify)

3. Who provided you with this service/event (select all that apply)?

Nadia Cayce-Gibson Brittany Couch Joy Cunningham Ivonn Ellis-Wiggan Karen Francis Becca Gourley Kim Helfgott Regenia Hicks Sharon Hunt Amy Johnson	Sandra Keenan Ken Martinez Yorkmit Mendieta Marie Niarhos Becky Ornelas David Osher Gwen Palmer Jeffrey Poirier Nick Read Reyhan Reid	Frank Rider James Sawyer Sandra Spencer Bruce Strahl Mary Tierney Edith Tuazon Kim Williams Cultural Competence Action Team (CCAT)
Other (please specify)

4. What was the time frame of this service/event?

 In the last 30 days

 In the last 60 days

 In the last 6 months

 Specific date(s) (please enter below):

TA Partnership Service/Event Feedback

5. The value/usefulness of the TA service/event:

	Excellent	Good	Fair	Poor
Please rate:

TA Partnership Staff Feedback

6. Courtesy/professionalism of TA Partnership staff providing the service:

	Excellent	Good	Fair	Poor
Please rate:

7. Knowledge level of TA Partnership staff providing the service:

	Excellent	Good	Fair	Poor
Please rate:

8. Timeliness of follow through/follow-up:

	Excellent	Good	Fair	Poor	N/A
Please rate:

Overall

9. Overall Satisfaction:

	Excellent	Good	Fair	Poor
Please rate:

10. Suggestions on further improving our TA services/events?

11. May we contact you regarding your experience? If so, please provide your e-mail address or phone number.

Email Address:
Phone Number:

12. Please check this box if you would like a response within 48 hours:

I would like a response within 48 hours.

Attachment 2: End-of-Email Message

Help improve our services by providing anonymous feedback! The TA Partnership is committed to providing quality and effective services and focusing on areas in need of improvement. We take pride in our work and value your feedback to ensure we maintain an excellent level of performance. Please use the following link to provide anonymous feedback [survey link].

1 Question 1 provides a drop-down menu for respondents to select one of the items selected.

2