On-Site Learning E On-Site Learning Event Feedback Form

OMB No. 0930-0197

Expiration Date: 03/31/2014

Attachment 1: On-Site Learning Event Feedback Form

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 9 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.

Identify your role within your system of care community:

Advocate Child Welfare Clinical Director Cultural/Linguistic Coordinator Early Childhood Education/Special Education Evaluator/Researcher Family Member/Caregiver	Federal Government Health Juvenile Justice Lead Family Contact Mental Health National Organization Principal Investigator/Project Director	Service Provider Social Marketing/Communications Substance Abuse Technical Assistance Coordinator Youth/Young Person Youth Coordinator/Youth Engagement Specialist
Other (please specify): ________________________

Check the box indicating the extent to which you agree with each item:

	Strongly Disagree	Disagree	Agree	Strongly Agree	Not Applicable
The presenters(s)/facilitator(s) clearly stated the learning objectives.
The information presented will help me be more effective in my role within my system of care (SOC) community.
The presenter(s)/facilitator(s) provided “how to” strategies and tools (handouts/materials/toolkit CD)
I will be able to use the information offered.
I will be able to effectively share the information with other members of my SOC community.
Enough time was allowed for discussion and questions.
The presentations were respectfully facilitated.
Due to my participation in this learning event, I:
Have a deeper understanding of LGBTQI2-S cultures.
Have greater knowledge of the challenges that children/youth who are LGBTQI2-S may experience.
Have an expanded understanding of supports/services that can foster resilience among children/youth who are LGBTQI2-S and their families.
Have an expanded understanding of how to enhance the cultural and linguistic competence of supports/services for children/youth who are LGBTQI2-S and their families.

Prior to this learning event, my content knowledge about providing culturally and linguistically competent supports and services for LGBTQI2-S children/youth was: Entry Level Intermediate Level Advanced Level

As a result of this learning event, my content knowledge about providing culturally and linguistically competent supports and services for LGBTQI2-S children/youth is: Entry Level Intermediate Level Advanced Level

Please share any recommendations for enhancing future learning events. We would welcome your feedback!

What additional information should we include in future TA Partnership learning events?

Any additional comments:

Thank you for your participation today!