Form TTA Tool TTA Tool TTA Tool

OMB No. 0930-0197

Expiration Date: 1/31/17

Appendix A

TA Network Continuous Quality Improvement (CQI) Survey

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 2-1057, Rockville, Maryland, 20857.

You are receiving this survey because you received technical assistance in the past three months from at least one member of the TA Network for Children’s Behavioral Health (you’ll be reminded about the specific services you received on the second page of this survey). The TA Network wants to make sure that it is meeting the needs of your System of Care (SOC) community and providing high quality technical assistance. Therefore, we appreciate you taking the time to provide feedback about your recent TA experience. The survey should take less than 10 minutes to complete.

<PAGE BREAK>

What system(s) and role(s) do you represent? (Please check as many as apply)

Court Representative

Cultural/Linguistic Competence Coordinator

Direct Service Provider

Evaluator/Researcher

Lead Family Contact/Family

Local Child Welfare agency

Local Early Childhood Agency

Local Education

Local Health Agency

Local Juvenile Justice Agency

Local Mental Health Agency

Local substance Abuse Agency

Managed Care Organization

Principal Investigator

Project Director

Social Marketing/Communications

State Child Welfare agency

State Early Childhood Agency

State Education/Special Education

State Health Agency

State Juvenile Justice Agency

State Medicaid Agency

State Mental Health Agency

State Substance Abuse Agency

TA Network

Technical Assistance Coordinator

Youth Engagement Specialist/Youth

Other (please specify) ________

Please select the type of SOC Grant/Cooperative Agreement your community/state has.

1 Year System of Care Expansion Planning Grant

4 Year System of Care Expansion Implementation Cooperative Agreement

6 Year Children’s Mental Health Initiative Cooperative Agreement

In what year was your grant or cooperative agreement funded? _______

<PAGE BREAK>

Our records indicate that in the past three months you received technical assistance from the following provider(s). Did you actually receive TA from these providers, and was that TA significant enough that you feel you could rate its usefulness?

TA Provider	Yes, I received significant TA from this provider	Yes, I received TA from this provider, but it was not significant	No, I did not receive TA from this provider in the last three months
<populated from TARS data>	Yes	Yes, but	No
<populated from TARS data>	Yes	Yes, but	No
<populated from TARS data>	Yes	Yes, but	No
<populated from TARS data>	Yes	Yes, but	No

In the next few screens you will be asked about the impact of the TA you received from each of these providers.

<PAGE BREAK>

<the following block of questions will be repeated for EACH significant TA provider endorsed above>

The following questions concern the TA you recently received from <inset TA Providers>.

Which of the following topics best describes what you discussed during your TA with <insert TA Providers> in the past three months? (choose all that apply)

<insert checklist of TA topics from TARS data>

Prior the TA your received from <insert TA Providers>, what level of mastery or competence did you have related to the topics discussed during your TA?

Complete Beginner					Intermediate					Fully Expert
0	1	2	3	4	5	6	7	8	9	10

Given what you learned from the TA from <insert TA Providers> (AND any follow up or experience afterward), how would you rate your current level of mastery or competence related to the topic provided by the TA?

Complete Beginner					Intermediate					Fully Expert
0	1	2	3	4	5	6	7	8	9	10

How much do you agree with the following statements about the TA you received from <insert TA Providers> in the past three months?

	Strongly Disagree	Somewhat Disagree	Neutral	Somewhat Agree	Strongly Agree
The TA was provided in a timely manner.	-2	-1	0	1	2
The TA was provided in a professional manner.	-2	-1	0	1	2
Overall, the TA was organized and coherent.	-2	-1	0	1	2
The TA provider(s) was/were credible and had a high level of relevant expertise.	-2	-1	0	1	2
The TA experience was informative.	-2	-1	0	1	2
Our needs are being met by the TA we receive.	-2	-1	0	1	2

What level of impact do you think the TA provided by <insert TA Provider> in the past three months will have on your work over the coming months?

None					Moderate					Profound and enduring
0	1	2	3	4	5	6	7	8	9	10

What, if anything, have/will you do differently as a result of your TA from <insert TA Providers>?

How much impact do you think the TA from <insert TA Providers> will have on the quality of System of Care teams, programs or system supports that you are part of?

None					Moderate					Profound and enduring
0	1	2	3	4	5	6	7	8	9	10

<PAGE BREAK>

<ONLY GRANTEES WHO WORKED WITH THREE OR MORE TA PROVIDERS WILL BE ASKED TO IDENTIFY WHICH ONES WERE MOST AND LEAST HELPFUL>

In the past three months, which of your TA providers was most helpful?

(Drop-down menu, pre-populated from TARS data)

What was most helpful about the TA they provided in the past three months?

In the past three months, were any of the TA providers less helpful than you think they could have been? (yes, no)

If yes, which of your TA providers was least helpful?

(Drop-down menu, pre-populated from TARS data)

If yes, how could they have been more helpful?

Would you like to add any additional feedback about your TA experience in the past three months?

Adapted from the Impact of Training and Technical Assistance (IOTTA) survey 7