Form Coaching Satisfact Coaching Satisfact Coaching Satisfaction Survey

Voluntary Customer Satisfaction Surveys to Implement Executive Order 12862 in the Substance Abuse and Mental Health Services Administration (SAMHSA)

Contractor Coaching Satisfaction Survey Attachment 1, 6-25-13

Coaching Satisfaction Survey

OMB: 0930-0197

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Attachment 1: SAMHSA System of Care Statewide Expansion Cooperative Agreement Coaching Impact Survey for Grantees


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 10 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.



Purpose: We value your opinions, thoughts, and feedback about the coaching you are receiving from the Technical Assistance (TA) Enterprise as part of your site’s System of Care Planning and/or Implementation Grant. Your answers to the following questions will help us better understand the impact of the coaching provided to your site as you work to accomplish the goals of the cooperative agreement, and they will help us plan for future grantees.


Directions: We suggest that the project director complete the survey with input from other team members to provide a comprehensive response. Please feel free to be candid in your responses. The survey should take about 15–20 minutes to complete.


Conditions of Privacy: Only individuals working specifically on continuous quality improvement (CQI) as part of the TA Enterprise will have access to your individual responses. The TA Enterprise CQI staff may aggregate and summarize your responses and send this aggregate summary of the results (not individual survey responses) to the TA Enterprise coaches.


We appreciate your time and effort providing this needed and valuable feedback.


For more information about this survey or any questions, you may contact Jeffrey Poirier at [email protected] or Joan Dodge at [email protected].







A. Please rate the extent to which you agree with each of the following questions:

My coach(es) is…

Strongly Disagree

(1)

Disagree

(2)

Neutral

(3)

Agree

(4)

Strongly Agree

(5)

NA

System of Care Values

  1. working to strengthen system of care values and principles.

O

O

O

O

O

O

Resources and Content Expertise

  1. supporting the assessment of the current status of system of care expansion efforts in our grantee site.

O

O

O

O

O

O

  1. providing content/technical expertise.

O

O

O

O

O

O

  1. providing multifaceted strategies and approaches for systems change.

O

O

O

O

O

O

  1. providing multiple resources that meet our needs.

O

O

O

O

O

O

  1. coordinating access to available TA resources.

O

O

O

O

O

O

  1. increasing peer support from other grantee sites.

O

O

O

O

O

O

Strategic Planning

  1. helping us to focus on the broader vision.

O

O

O

O

O

O

  1. helping to prioritize components of the strategic plan.

O

O

O

O

O

O

  1. helping to develop alliances and partnerships.

O

O

O

O

O

O

  1. identifying challenges to address.

O

O

O

O

O

O

  1. brainstorming options/solutions to the challenges.

O

O

O

O

O

O

  1. helping us to implement action steps.

O

O

O

O

O

O

  1. helping to leverage opportunities to achieve goals.

O

O

O

O

O

O

  1. helping to track accomplishments and outcomes.

O

O

O

O

O

O

Relationship

  1. building a positive and trusting relationship with us.

O

O

O

O

O

O

  1. accessible.

O

O

O

O

O

O

  1. flexible and adapting to our needs.

O

O

O

O

O

O

  1. responsive in a timely manner.

O

O

O

O

O

O

  1. giving us honest feedback.

O

O

O

O

O

O

  1. supporting the accomplishment of our grant goals and objectives.

O

O

O

O

O

O

  1. helping to facilitate our overall goal of widespread implementation of the system of care approach.

O

O

O

O

O

O

Comments





B. Please share some information about the impact of the coaching to date.


  1. Describe the areas where your coach(es) have been the most helpful.







  1. Describe any progress that your grantee site has made since the coaching for this grant began.







  1. Describe any challenges faced by your grantee site and how the coaching may have helped your team effectively respond to these challenges.







  1. On a scale of 1-5, please rate the quality/strength of your relationship with your coach(es).

O Poor O Fair O Good O Very Good O Excellent


  1. Please share any suggestions you have to improve the coaching going forward.








Thank you for your time!


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File Typeapplication/msword
File TitleTransformation Facilitation Survey (baseline)
AuthorLan T. Le
Last Modified ByJeffrey M. Poirier
File Modified2013-06-25
File Created2013-05-22
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