Form 1 Comprehensive Site Visit

OMB Number 0915-0212
Expiration date: 7/31/2015
Ryan White Care Act Comprehensive Site Visit Baseline Survey
Thank you for taking the time to complete and submit this brief survey. We are interested in learning
about your experiences with the Comprehensive Site Visit that you recently received. Your insight and
feedback are very valuable to the TA evaluation team and HRSA/HAB program personnel in making
decisions about the training and technical assistance provided to grantees through the Ryan White
HIV/AIDS program.
Only HRSA/HAB program personnel and evaluators will be able to identify and link survey responses to
each grantee (that completes the survey). Any reports developed for individuals not involved with the
development, management or evaluation of the HRSA/HAB Ryan White Technical Assistance Program
will not contain any information identifying individual grantees.
Your participation is highly recommended and your feedback is instrumental to improving the delivery of
the Comprehensive Site Visits. There is no penalty for refusal to participate, and you are free to withdraw
your consent and participation in this survey at any time.
If you have any questions about the survey, encounter any errors in the online information, or have
suggestions for improving this process, please contact your TA Coordinator.
Thank you again for your participation in this survey!

I Agree to participate >
I DO NOT Agree to participate>

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 0915-0212. Public reporting
burden for this collection of information is estimated to average 10 minutes 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
10-29, Rockville, Maryland, 20857.

OMB Number 0915-0212
Expiration date: 7/31/2015
Screen 2
Grantee Name:

Project Code:

TA Type:

TA Coordinator:

Date TA Initiated:

Date TA Completed:

Consultant Name 1:

Grantee Email:

Consultant Name 2:
Consultant Name 3:
Please rate your agreement with the following statements.
1. The comprehensive site visit achieved the agreed upon goals.
Strongly Agree

Agree

Not Sure/

Disagree

Uncertain

Strongly
Disagree

2. The comprehensive site visit met my expectations set from/based on pre-planning project officer
guidance and discussions.
Strongly Agree

Agree

Not Sure/

Disagree

Uncertain

Strongly
Disagree

3. The comprehensive site visit followed the agreed upon agenda.
Strongly Agree

Agree

Not Sure/
Uncertain

Disagree

Strongly
Disagree

4. Below are a number of statements. Please indicate whether (or which) of the following systems
and operations you anticipated being affected by the site visit. (check all that apply)
( ) Not Applicable
( ) Capacity Expansion, such as:
□ Increase in number of clients being served
□ Increase in the amount and type of services being offered to clients
□ Offering services not previously provided
□ Providing a greater amount of existing services to a greater percentage of
existing clients
□ Professional Development, such as:
□ Staff learned new skills, e.g., new methods, modalities
□ Staff increased facility with existing skills, e.g., better case management strategies
□ Systems Improvement, such as:
□ Improved use of Management Information Systems, e.g., CAREWare, RSR
□ Improved finance and accounting, e.g., tracking program income, unit cost, sliding fee
□ Coordination of care, e.g., case management and client flow management
□ Program Development, such as:
□ Access to care

OMB Number 0915-0212
Expiration date: 7/31/2015
□ ADAP
□ Comprehensive Planning
□ Unmet need
□ Other: Please Explain
□ Other Development. Please explain:

Please respond to the following statements for each consultant who facilitated your
comprehensive site visit. Additional statements will be presented if you received assistance from
more than one consultant.
5. Consultant 1 (name from above/system) had the professional knowledge and expertise to facilitate
the site visit in an effective manner.
Strongly Agree

Agree

Not Sure/

Disagree

Uncertain
5a.

Consultant 2 (name from above/system) had the professional knowledge and expertise to
facilitate the site visit in an effective manner.
Strongly Agree

Agree

Not Sure/

Disagree

Uncertain
5b.

Strongly
Disagree

Strongly
Disagree

Consultant 3 (name from above/system) had the professional knowledge and expertise to
facilitate the site visit in an effective manner.
Strongly Agree

Agree

Not Sure/

Disagree

Uncertain

Strongly
Disagree

6. Consultant 1 (name from above/system) completed all the work in a culturally competent manner.
Strongly Agree

Agree

Not Sure/

Disagree

Uncertain
6a.

Consultant 2 (name from above/system) completed all the work in a culturally competent manner.
Strongly Agree

Agree

Not Sure/

Disagree

Uncertain
6b.

Strongly
Disagree

Strongly
Disagree

Consultant 3 (name from above/system) completed all the work in a culturally competent manner.
Strongly Agree

Agree

Not Sure/

Disagree

Strongly

OMB Number 0915-0212
Expiration date: 7/31/2015
Uncertain

Disagree

7. GEARS, Inc. effectively coordinated the pre-planning site visit requirements and the logistical needs
for the comprehensive site visit.
Strongly Agree

Agree

Not Sure/

Disagree

Uncertain

Strongly
Disagree

N/A

8. My organization has the capacity at this time (i.e., staff, resources, budget) to implement the changes,
improvements, and/or information provided during the comprehensive site visit.
Strongly Agree

Agree

Not Sure/

Disagree

Uncertain

Please provide any other comments, concerns, or suggestions in the space below.

SUBMIT>

Strongly
Disagree

OMB Number 0915-0212
Expiration date: 7/31/2015

Ryan White Care Act Comprehensive Site Visit Follow-up Survey
Thank you for taking the time to complete and submit this brief survey. We are interested in learning
about your experiences with the Comprehensive Site Visit your organization received approximately 6months ago. Your insight and feedback are very valuable to the TA evaluation team and HRSA/HAB
program personnel in making decisions about the training and technical assistance provided to grantees
through the Ryan White HIV/AIDS program.
Only HRSA/HAB program personnel and evaluators will be able to identify and link survey responses to
each grantee (that completes the survey). Any reports developed for individuals not involved with the
development, management or evaluation of the HRSA/HAB Ryan White Technical Assistance Program
will not contain any information identifying individual grantees.
Your participation is highly recommended and your feedback is instrumental to improving the delivery of
the Comprehensive Site Visits. There is no penalty for refusal to participate, and you are free to withdraw
your consent and participation in this survey at any time.
If you have any questions about the survey, encounter any errors in the online information, or have
suggestions for improving this process, please contact your TA Coordinator.
Thank you again for your participation in this survey!
I Agree to participate >
I DO NOT Agree to participate>

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 0915-0212. Public reporting burden for this collection of
information is estimated to average 10 minutes 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 10-29, Rockville, Maryland, 20857.

OMB Number 0915-0212
Expiration date: 7/31/2015

Screen 2
Grantee Name:

Grantee Email:

Your Name: (Optional)

Are you the person who completed the first survey?
○ Yes

Project Code:

○ No

TA Type:

TA Coordinator:
Date TA Initiated:

Date TA Completed:

Consultant Name 1:
Consultant Name 2:
Consultant Name 3:

Please rate your agreement with the following statements.
1. The comprehensive site visit achieved the agreed upon goals.
Strongly Agree

Agree

Not Sure/

Disagree

Uncertain

Strongly
Disagree

2. The comprehensive site visit met my expectations set from/based on pre-planning project officer
guidance and discussions.
Strongly Agree

Agree

Not Sure/

Disagree

Uncertain

Strongly
Disagree

3. The comprehensive site visit followed the agreed upon agenda.
Strongly Agree

Agree

Not Sure/
Uncertain

Disagree

Strongly
Disagree

4. Below are a number of statements. Please indicate whether (or which) of the following systems
and operations you anticipated being affected by the site visit. (check all that apply)
( ) Not Applicable
( ) Capacity Expansion, such as:
□ Increase in number of clients being served
□ Increase in the amount and type of services being offered to clients
□ Offering services not previously provided
□ Providing a greater amount of existing services to a greater percentage of
existing clients
□ Professional Development, such as:
□ Staff learned new skills, e.g., new methods, modalities
□ Staff increased facility with existing skills, e.g., better case management strategies

OMB Number 0915-0212
Expiration date: 7/31/2015

□ Systems Improvement, such as:
□ Improved use of Management Information Systems, e.g., CAREWare, RSR
□ Improved finance and accounting, e.g., tracking program income, unit cost, sliding fee
□ Coordination of care, e.g., case management and client flow management
□ Program Development, such as:
□ Access to care
□ ADAP
□ Comprehensive Planning
□ Unmet need
□ Other: Please Explain
□ Other Development. Please explain:

5. My organization had the capacity at the time of comprehensive site visit (i.e., staff, resources,
budget) to implement the changes, improvements, and/or information provided during the site
visit.
Strongly Agree

Agree

Not Sure/

Disagree

Uncertain

Strongly
Disagree

Please respond to the following statements for each consultant who facilitated your
comprehensive site visit. Additional statements will be presented if you received assistance from
more than one consultant.
6. Consultant 1 (name from above/system) had the professional knowledge and expertise to
facilitate the site visit in an effective manner.
Strongly Agree

Agree

Not Sure/

Disagree

Uncertain
6a.

Consultant 2 (name from above/system) had the professional knowledge and expertise to
facilitate the site visit in an effective manner.
Strongly Agree

Agree

Not Sure/

Disagree

Uncertain
6b.

Strongly
Disagree

Strongly
Disagree

Consultant 3 (name from above/system) had the professional knowledge and expertise to
facilitate the site visit in an effective manner.
Strongly Agree

Agree

Not Sure/
Uncertain

Disagree

Strongly
Disagree

OMB Number 0915-0212
Expiration date: 7/31/2015

7. Consultant 1 (name from above/system) completed all the work in a culturally competent manner.
Strongly Agree

Agree

Not Sure/

Disagree

Uncertain
7a.

Consultant 2 (name from above/system) completed all the work in a culturally competent manner.
Strongly Agree

Agree

Not Sure/

Disagree

Uncertain
7b.

Strongly
Disagree

Strongly
Disagree

Consultant 3 (name from above/system) completed all the work in a culturally competent manner.
Strongly Agree

Agree

Not Sure/
Uncertain

SUBMIT>

Disagree

Strongly
Disagree