Form Surveys

Attachment 1: Annual Webinar Survey
OMB No. 0930-0197
Expiration Date: 03/31/14
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 8 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.

1. Of the proposed Webinar content areas below, please identify those Webinars you would attend if the TA
Partnership offered them:
Child Welfare
Cultural Competence
Education
Family Engagement
Healthcare Reform

Juvenile Justice
Linguistic Competence
Organizational Development
Primary Care
Rural Issues

Service Delivery Systems
Staff Structure and Retention
Sustainable Funding
Youth Engagement
Substance Abuse

If there are any other Webinar content areas/topics you would like to propose, we would greatly appreciate if you
would list them here _______________________________________________
2. Thinking back over the past 12 months, how many TA Partnership Webinars have you attended?
None
1-3
4-6
More than 6
The TA Partnership would like your feedback on how to make the Webinar experience more engaging and effective.
Please identify your level of agreement with the following statements

Strongly
Disagree
3. The current Webinar format—presenter(s) with
PowerPoint presentation(s)—meets my technical
assistance needs.
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Neither
Disagree Agree nor
Disagree

Agree

Strongly
Agree

Strongly
Disagree

Neither
Disagree Agree nor
Disagree

Agree

Strongly
Agree

4. The current Webinar format—presenter(s) with
PowerPoint presentation(s)—is engaging.

5. The current Webinar format—presenter(s) with
PowerPoint presentation(s)—matches my learning style.

6. I would like to hear more from former or current
communities who would share “how-to” examples.

7. A more effective format for delivering technical
assistance via a Webinar would be to structure Webinars
with longer question and answer periods.

8. A more effective format for delivering technical
assistance via a Webinar would be to have a panel of
former and (or) current community presenters/facilitators.

9. The webcams make the presentation more engaging.

10. Conducting polls makes the presentation more
engaging.

11. I would be willing to participate in a short-term (two months with 1 to 2 calls each month) workgroup to identify
Webinar topics and identify presenters. (If so, please provide your name and contact info: _______)
12. If there is a colleague or other person you would like to recommend as a presenter, please share their name and the
topic they could present on: ____________
13. Please include your contact information if you would like to be contacted regarding your responses: _______

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Attachment 2: Specific Webinar Survey
OMB No. 0930-0197
Expiration Date: 03/31/14
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 5 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.

[Title and date of webinar]
Please provide us with your feedback on today's Webinar by answering the questions below. The form should
only take a few minutes to complete and all responses will be completely anonymous. Your participation is
voluntary.

1. My role can best be described as (please check as many as apply):
My role can best be described as
(please check as many as apply):
Advocate

Federal Government
Health

Social
Marketing/Communications

Juvenile Justice

Child Welfare
Cultural/Linguistic Coordinator

Lead Family Contact

Education/Special Education

National Organization
Principal Investigator/Project
Director

Evaluator/Researcher

Substance Abuse
Technical Assistance
Coordinator

Mental Health

Early Childhood

Service Provider

Youth/Young Person
Youth Coordinator

Family Member/Caregiver
Other (please specify)

2. Overall, how would you rate the quality of this Webinar, such as the communication style of
presenter(s) and the clarity of the Webinar content?
Poor

Fair

Good

1

Excellent

3. Overall, how knowledgeable about the Webinar’s topic(s) were you prior to this call?
Not Knowledgeable

Somewhat Knowledgeable

Very Knowledgeable

4. Will you directly apply the information in your system of care community role?
No

Maybe

Yes

5. The information presented on the Webinar helped me learn about:
Neither
Strongly
Disagree Agree nor
Disagree
Disagree

Agree

Strongly
Agree

[item depends on webinar content]
[item depends on webinar content]
[item depends on webinar content]
[item depends on webinar content]

6. Do you intend to share information from this Webinar with community stakeholders/partners?
No

Maybe

Yes

7. If you answered “Yes” to question 6., please describe the system of care community roles of the
individuals with whom you might share the Webinar content.

8. Did the video component of the presentation (seeing the presenters through video) make the
presentation more engaging?
Yes

No

I was not able to see the video
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component
Please describe any comments you have about the video portion of the Webinar:

9. Please describe any additional information you would have liked included in this Webinar.

10. Do you have suggestions for future Webinar topics? We’d like to hear them! Please share your ideas
here.

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Attachment 3: Cultural Competence Action Team Survey
OMB No. 0930-0197
Expiration Date: 03/31/14
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 12 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.

“Help Us Improve!”
The TA Partnership is committed to continually improving its work with systems of care (SOC) and supporting
the cultural and linguistic competence (CLC) of systems of care. To do this, we need feedback from you. The
Cultural Competence Action Team (CCAT) would appreciate your feedback on the following questions so that
we can improve our service to you.
The CCAT established the CLC Community of Practice (CLC COP), which is an affinity group based on
similar roles or areas of interest in CLC. The CLC COP meets regularly by phone and includes five Learning
Communities that meet separately: (1) African Heritage; (2) Asian American, Native Hawaiian, and Other
Pacific Islander; (3) Fatherhood; (4) Latino; and (5) Lesbian, Gay, Bisexual, Transgender, Questioning,
Intersex, and Two-Spirit (LGBTQI2-S). This survey asks questions about the CLC COP and its services.

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I) Individualized Cultural and Linguistic Competence
Consultation/Technical Assistance
The following questions pertain to individualized CLC consultation/technical assistance (TA) provided by
CCAT members to you or to your community. CCAT members include Ken Martinez, Larry Brown, Nadia
Cayce-Gibson, Karen Francis, Becky Ornelas, Jeffrey Poirier, Janet Soohoo, and Amy Johnson.

1. Did you receive individualized TA from at least one of the CCAT members listed above at
least once during the previous six months?
Yes

No

2. Please rate your agreement with the following statements based on your experience during
the previous six months. Please respond about your general experience if you have received TA
from more than one CCAT member.
Strongly
Disagree

Somewhat
Disagree

Somewhat
Agree

Strongly
Agree

My TA request(s) was responded to in a timely manner.
The TA was provided in a courteous manner.
I was satisfied with the TA provided.
The TA met my needs.

3. If you would like to share additional feedback about the individualized CLC TA you
received, please share your comments here.

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II) Cultural Linguistic Competence Community of Practice Calls and
Webinars
1. Please select the CLC COP conference calls/webinars you participated in during the
previous six months:
March 11, 2010 - Fatherhood Call: Fatherhood and Native American Culture
March 17, 2010 - Asian American, Native Hawaiian, and Other Pacific Islander Learning
Community Call: Using Health Information Technology as a Tool to Eliminate Disparities
April 1, 2010 - CLC Community of Practice Call: Cultural and Linguistic Competence Implementation
Guide Overview
April 6, 2010 - CLC Coordinators Call
April 8, 2010 - Fatherhood Call:
April 15, 2010 - Latino Learning Community Call: Working Effectively with the New Immigrant Latino
Community in MeckCares System of Care
April 20, 2010 - LGBTQI2-S Learning Community Call: Assets-Based Approaches
April 28, 2010 - African Heritage Learning Community Call: Discussing the AHLC Action Plan and
the Initiative for Boys of African Heritage
May 11, 2010 - African Heritage Learning Community, Latino Learning Community, and Asian
American, Native Hawaiian, and Other Pacific Islander Learning Community Joint Call: Refugee Foster
Children: Hope Rekindled, Lives Transformed
May 13, 2010 - Fatherhood Call: Fathers and their Involvement with the Child Welfare System
May 21, 2010 - CLC Community of Practice Call: Modifying Evidenced-Based Practice to Increase
Cultural Competence
June 1, 2010 - CLC Coordinators Call
June 10, 2010 - Fatherhood Call: Expanding Our Capacity for Working with Teen Fathers: Beginning the
Conversation
June 24, 2010 - African Heritage Learning Community Call: "Good Hair" – The Image of Self that We
Pass on to Our Children of African Heritage
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August 3, 2010 - CLC Coordinators Call
August 12, 2010 - Fatherhood Call: Resiliency in Fatherhood: One Man’s Journey through Recovery
I have not participated in any CLC COP calls/webinars in the previous 6 months

2. Please rate your agreement with the following statements based on your experience during
the previous six months. Please respond about your general experience if you participated in
more than one call/webinar during this period.
Strongly
Disagree

Somewhat
Disagree

Somewhat
Agree

Strongly
Agree

The topics discussed provided information that has
helped (or will help) me to infuse CLC within my SOC.
The information provided was clear and understandable.
The conference call(s)/webinar(s) provided valuable
opportunities for peer learning and networking.
Presenters were knowledgeable about the information
they provided.
Presenters engaged participants in discussions.
The frequency of CLC COP conference calls/webinars
meets my CLC needs.
The duration of CLC COP conference calls/webinars
meets my CLC needs.

3. If you would like to share additional feedback about the CCAT conference calls/webinars
you have participated in, please share your comments here.

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III) Cultural and Linguistic Competence Community of Practice
Resources
For each of the following CLC COP resources, please indicate the extent to which you agree with the following
statement. Also, please include any comments you would like to share about these resources.

1. The resource supports my efforts to integrate and implement CLC in my community role.
I Have
Not
Strongly Somewhat Somewhat Strongly
Accessed
Disagree Disagree Agree
Agree
This
Resource
Cultural and Linguistic Competence Checklist for
Communities
Cultural and Linguistic Competence Implementation
Guide
A Cultural Competency Toolkit: Ten Grant Sites Share
Lessons Learned
Sample Cultural and Linguistic Competence Budget
Sample Cultural and Linguistic Competence Committee
Description
Sample Cultural and Linguistic Competence Plan
Sample Job Description for Cultural and Linguistic
Competence Coordinators
A System of Care Team Guide to Implementing
Cultural and Linguistic Competence
Comments

2. Please share additional suggestions for resources that you would like the CLC COP to
provide.

IV) Cultural and Linguistic Competence Community of Practice Web
Site
1. I have accessed the CLC COP Web site (http://www.tapartnership.org/COP/CLC/) at least
once during the previous six months.
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Yes

No

2. Please rate:
Strongly
Disagree

Somewhat
Disagree

Somewhat
Agree

Strongly
Agree

The CLC COP Web site is easy to navigate — I easily
find what I am looking for.
The available material helps me to integrate and
implement CLC in my community.

3. If you have any suggestions for improving the CLC COP Web site, please share your
feedback.

V) Cultural and Linguistic Competence Community of Practice
Overall
1. Please share additional suggestions for improving any other aspect of the CLC COP.

2. Thinking about all the resources and supports the CLC COP provides, have these helped
you to bring about positive change in any of the following areas? Please select all that apply.
Continuous quality improvement/evaluation
Culturally and linguistically competent care
Effective collaboration and communication
Family-driven care
Governance
Logic model development
Service delivery
Social marketing
Start-up, relationship building
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Strategic planning and associated plans
Sustainability and finance
Workforce development
Youth-guided care

3. Are there any additional examples of impacts you would like to share?

VI) Respondent Background Information
The following questions will help us contextualize the information you have provided.

1. Are you affiliated with a currently funded system of care?
Yes

No

Unsure

2. What is your role?

3. In which year did your SOC first receive CMHS funding through the Comprehensive
Community Mental Health Services for Children and Their Families Program?
2003 or earlier (graduated)

2006

2004

2007

2005

2008

2009

4. How long have you been involved with your SOC?
3 months or less
4 to 12 months
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more than 1 year, but less than 2 years
2 years or more

5. I am a:
Clinical Director

Project Director or Principal Investigator

Community Partner

Service Provider

Cultural and Linguistic Competence Coordinator

Social Marketing Coordinator

Evaluator

Technical Assistance Coordinator

Family Member

Youth

Lead Family Contact

Youth Coordinator/Youth Engagement Specialist

Other (please specify)

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