Form A Attachment A-MIECHV On-Site Compliance Review Awardee Fe

OMB Control No. 0915-0212

Expiration Date: 07/31/2021

Maternal, Infant, and Early Childhood

Home Visiting (MIECHV) On-site Compliance Review

Awardee Feedback Form

OMB Control No. 0915-0212

Expiration Date: 7/31/2021

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 .25 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 18N136B, Rockville, Maryland, 20857.

Introduction Letter

* ^1. Dear Awardee,

Thank you for participating in the recent HRSA MIECHV Compliance Review 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 successes, recommendations for improvement, and/or challenges 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 Project Manager, [name, email, phone number]. We look forward to your feedback.

The dropdown box above will list the current HRSA project officer’s names.

Pre-Site Visit

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

• ^{3. The planning for the site visit was timely and responsive to our needs.}

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^{4. The Site Visit Assessment Tool helped us prepare for the site visit.}

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^{5. The pre-site visit planning call helped us prepare for the site visit.}

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^{6. Expectations of the site visit were clearly articulated.}

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

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

Site Visit – Programmatic Consultant

This section is an evaluation of the programmatic consultant assigned to your site visit. When answering these questions please think specifically about that member of the site visit team.

• ^{8. Site Visit Staff:}

  

• Who is the Programmatic Consultant that visited you?

The Programmatic Consultant…

• ^{9. Exhibited appropriate knowledge of MIECHV programs.}

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^{10. Was well prepared, demonstrated knowledge of our organization, the Site Visit Assessment} Tool and the HRSA site visit process.

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^{11. Was objective and professional}

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^{12. Effectively utilized the Site Visit 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

• ^{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

15. Please provide any additional comments concerning the programmatic consultant.

Site Visit - Fiscal Consultant

This section is an evaluation of the fiscal consultant assigned to your site visit. When answering these questions please think specifically about that member of the site visit team.

• ^{16. Site Visit Staff:}

• Who is the Fiscal Consultant that visited you?

The Fiscal Consultant…

• ^{17. Exhibited appropriate knowledge of MIECHV programs}

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^{18. Was well prepared, demonstrated knowledge of our organization, the Site Visit Assessment} Tool and the HRSA site visit process.

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^{19. Was objective and professional.}

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^{20. Effectively utilized the Site Visit 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

• ^{22. The site visit debriefing provided an accurate account of the discussions during the site visit.}

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

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

^{Site Visit - Notetaker}

^{This section is an evaluation of the notetaker assigned to your site visit. When answering these questions please think specifically about that member of the site visit team.}

• ^{1. The note taker demonstrated professionalism in supporting the site visit.}

• 
  ^{Disagree Strongly Disagree Undecided Agree Strongly Agree N/A}

^{2. Please provide any additional comments concerning the notetaker.}

^{Thank you for completing this survey! If you have additional comments or questions about this survey please contact the Project Manager, [name, email, phone number].}

1