E Attachment E - Site Visit Assessment Form

OMB Control No. 0915-0212
Expiration Date: 5/31/2018

IDIQ TA Site Visit Evaluation-2016
Introduction Letter
* 1. Dear Grantee,
Thank you for participating in the recent MIECHV IDIQ TA site visit. In an effort to continuously improve our
processes we would like to get your feedback on the site visit and the staff assigned to the site visit. This
survey will allow us to gather feedback and report any complements, recommendations for improvement,
and/or complaints to HRSA immediately.
Your feedback helps us review our processes, assess our staff, and make any necessary improvements.
Your responses are anonymous and the survey should take less than 10 minutes to complete. Please
complete it within 5 business days of the date of receipt. If you have questions about the survey please
contact the MIECHV IDIQ TA Manager, Carly Mensah at [email protected] or 301-459-0100. We
look forward to your feedback.
The Bizzell Group
Grantee

Your Role on the Project

Project Officer

Please Select

This section is an evaluation of the pre-site visit activities that occurred in preparation for your site visit.

IDIQ TA Site Visit Evaluation-2016
Pre-Site Visit
When answering these questions please think specifically about the planning phase of the site
visit.
* 2. Did you participate in a pre-site visit conference call?
Yes
No

OMB Control No. 0915-0212
Expiration Date: 5/31/2018

IDIQ TA Site Visit Evaluation-2016

* 3. The planning for the site visit was timely and responsive to our needs.
Disagree Strongly

Disagree

Undecided

Agree

Strongly Agree

N/A

Strongly Agree

N/A

Agree

Strongly Agree

N/A

Agree

Strongly Agree

N/A

* 4. The Site Visit Assessment Tool helped us prepare for the site visit.
Disagree Strongly

Disagree

Undecided

Agree

* 5. The pre-site visit planning call helped us prepare for the site visit.
Disagree Strongly

Disagree

Undecided

* 6. Expectations of the site visit were clearly articulated.
Disagree Strongly

Disagree

Undecided

7. Please provide any additional comments/ recommendations about the pre-site visit process.

OMB Control No. 0915-0212
Expiration Date: 5/31/2018

IDIQ TA Site Visit Evaluation-2016
Site Visit - Program Specialist
This section is an evaluation of the programmatic expert assigned to your site visit. When answering
these questions please think specifically about that member of the site visit team.
* 8. Site Visit Staff:
Specialist Assigned to Your Visit
Program Specialists

* 9. Exhibited appropriate knowledge of the MIECHV programs.
Disagree Strongly

Disagree

Undecided

Agree

Strongly Agree

N/A

* 10. Was well prepared, demonstrating knowledge of our organization, the Site Visit Assessment Tool
and the HRSA site visit process.
Disagree Strongly

Disagree

Undecided

Agree

Strongly Agree

N/A

Undecided

Agree

Strongly Agree

N/A

* 11. Was objective and professional
Disagree Strongly

Disagree

* 12. Effectively utilized the Assessment Tool and the sample questions to frame the discussion and
to add clarity to the items being assessed.
Disagree Strongly

Disagree

Undecided

Agree

Strongly Agree

N/A

* 13. Was helpful and provided onsite technical assistance when possible, and as appropriate.
Disagree Strongly

Disagree

Undecided

Agree

Strongly Agree

N/A

* 14. The site visit debriefing provided an accurate account of the discussions during the site visit.
Disagree Strongly

Disagree

Undecided

Agree

Strongly Agree

N/A

OMB Control No. 0915-0212
Expiration Date: 5/31/2018
15. Please provide any additional comments concerning the programmatic expert.

IDIQ TA Site Visit Evaluation-2016
Site Visit - Fiscal Specialist
This section is an evaluation of the fiscal expert assigned to your site visit. When answering these questions
please think specifically about that member of the site visit team.
* 16. Site Visit Staff:
* 17. Exhibited appropriate knowledge of the MIECHV programs
Disagree Strongly

Disagree

Undecided

Agree

Strongly Agree

N/A

Specialist Assigned to Your Visit

Fiscal Specialists

* 18. Was well prepared, demonstrating knowledge of our organization, the Site Visit Assessment Tool
and the HRSA site visit process.
Disagree Strongly

Disagree

Undecided

Agree

Strongly Agree

N/A

Undecided

Agree

Strongly Agree

N/A

* 19. Was objective and professional.
Disagree Strongly

Disagree

OMB Control No. 0915-0212
Expiration Date: 5/31/2018
* 20. Effectively utilized the assessment tool and the sample questions to frame the discussion and to
add clarity to the items being assessed.
Disagree Strongly

Disagree

Undecided

Agree

Strongly Agree

N/A

* 21. Was helpful and provided onsite technical assistance when possible, and as appropriate.
Disagree Strongly

Disagree

Undecided

Agree

Strongly Agree

N/A

* 22. The site visit debriefing provided an accurate account of the discussions during the site visit.
Disagree Strongly

Disagree

Undecided

Agree

Strongly Agree

23. Please provide any additional comments concerning the fiscal expert.

N/A