C Attachment C - HV-PMCQI Individualized TA Survey

OMB No: 0915-0212

Expiration date: 07/31/2021

HV-PM/CQI TA Center Targeted TA 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 0915-0212. Public reporting burden for this collection of information is estimated to average .08 hours 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 14N136B, Rockville, Maryland, 20857.

1. Overall, how satisfied were you with the one-on-one technical assistance request?

• Extremely satisfied

• Satisfied

• Somewhat satisfied

• Somewhat dissatisfied

• Dissatisfied

• Extremely dissatisfied

2. [If respondent chooses option d-f in #1] Please explain why you were dissatisfied with the technical assistance. Open-ended text response

3. How helpful was the content provided by your TA Specialist in addressing your TA needs?

• Extremely helpful

• Very helpful

• Moderately helpful

• Slightly helpful

• Not at all helpful

4. [If respondent chooses options c-e in #3] How could your TA Specialist’s technical assistance have been more helpful in addressing your needs with this request? Open-ended text response

5. Have you or your team taken any action steps as a result of this one-on-one TA request?

• Yes

• No

6. [If respondent chooses “yes” in #5] Please describe 1-2 action steps you or your team have taken as a result of the one-on-one TA request. Open-ended text response

7. [If respondent chooses “no” in #5] Please describe how the technical assistance could have better supported you and your team move to action. Open-ended text response

8. Overall, how satisfied were you with the following items regarding your TA Specialist?

	1 = Extremely satisfied; 2 = Satisfied; 3 = Somewhat satisfied; 4 = Somewhat dissatisfied; 5 = Dissatisfied; 6 = Extremely dissatisfied
a. The responsiveness of my TA Specialist	1 2 3 4 5 6
b. The communication with my TA Specialist.
c. My TA Specialist’s ability to understand the unique nature of my needs
d. My TA Specialist’s knowledge of the technical assistance topics.

9. To what extent did the one-on-one technical assistance improve your organization’s capacity in [insert outcome/objective].

• Greatly improved capacity

• Moderately improved capacity

• Slightly improved capacity

• Did not improve capacity

10. What aspects of the technical assistance request were most useful? Open-ended text response

11. In what ways could your TA Specialist better support you in future technical assistance requests? Open-ended text response

12. Please indicate the role with which you most closely identify.

• MIECHV Program Manager / Project Supervisor

• Home Visiting Resource Coordinator

• Home Visiting Program Manager

• Data Manager / CQI Specialist

• Public Health Analyst

• Other, please explain:__________