Form 001_ORHP_SORH SORH TA Form

OMB No. 0915-0322
Exp. Date 06/31/2010

STATE OFFICES OF RURAL HEALTH GRANT PROGRAM (SORH)
TECHNICAL ASSISTANCE DATA COLLECTION FORM
Date Submitted:
State:

Name of Grantee:

Dates of Budget Period:

Fiscal Year of Grant:

Definitions:
Technical Assistance (TA) Encounter: Any activity that is planned, funded, organized,
administered or provided by SORH that results in the delivery of substantive information,
advice, education or training directly to a client(s). TA must be provided face to face, through
teleconference / webinar technology or via in-depth telephone and e-mail interactions that result
in the delivery of substantive service or subject content (problem solving, proposal feedback,
regulation interpretation, grant application guidance etc.) to a client. Relatively brief/routine
telephone and email responses and direct mass mailings are not considered TA for the purpose of
this measure. A client usually requests TA or receives an invitation from SORH to participate in
scheduled/formal TA activities such as workshops, conferences, seminars, meeting or training
sessions.
Client: Any individual, group or organization interested in rural health. Examples include but are
not limited to: providers/technicians, hospitals, clinics, networks, agencies, associations,
organizations, academic institutions, government officials, communities, partners and other
stakeholders. Affiliated individuals (i.e. members of an association or organization) would
normally be considered a single client. Example - SORH addressing State Rural Health
Association about grant opportunities. Non-affiliated individuals (i.e. hospital administrators or
nurses) would normally be considered as multiple clients. Example – hospital staff attending a
SORH sponsored workshop on quality and performance improvement.
Technical Assistance Data:
Responses should be submitted directly to the SORH Program Coordinator within 30 days of the
end of the budget period.
1) Report the total number of technical assistance (TA) encounters provided directly to
clients within your state by SORH.
2) Report the total number of clients within your State that received technical assistance
directly from SORH.
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 valid OMB control number. The OMB control number for this project is 0915-0322. Public reporting burden for this
collection of information is estimated to average 12.5 hours per response, including the time for reviewing instructions, searching existing
data sources, 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: HRSA Reports Clearance Officer, 5600 Fishers
Lane, Room 10-33, Rockville, MD, 20857.