Regional Extenion Center

Regional Extension Center Cooperative Agreement Program (CRM Tool)

0955-0009 Workforce Survey_v9_2016

Regional Extenion Center

OMB: 0955-0009

Document [doc]
Download: doc | pdf

Form Approved

OMB No. 0955-0009

Exp. Date 05/16/2017













Workforce Training Program Evaluation











According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0955-0009. The time required to complete this information collection is estimated to average ( hours)(minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer


Workforce Training Program Evaluation Form



The Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology is distributing this survey to collect information about its Workforce Training Program. Your participation is greatly appreciated. Your answers are completely confidential. If you have any questions about this survey please contact xxxxxx.



Tell us about the training you took.

  1. Which educational institution sponsored the training you participated in?

[WILL BE PRE-POPULATED WITH ALL EDUCATIONAL INSTITUTIONS IN THE GIVEN CONSORTIUM.]

  1. What is the title of the training you took?

  1. Training Title:

a. __________________

b. Do not know

  1. When did you take this training?

1. Training Date:
a. __________________

b. Do not know


4) How was the training delivered (i.e., format)?




[CHECK ALL THAT APPLY.]

  1. In-person

  2. Webinar

  3. Self-paced on-line training

  4. Instructor-led online training

  5. Video conference

  6. Virtual discussion forums

  7. Other __________________

5) Did you complete the training

1. Yes (skip to question 7)

2. No (go to question 6)

6) Why didn’t you complete the training?

1. I was too busy to complete training.

2. Training was not offered during a time when I was available.

3. There were too many modules for me to complete.

4. I only completed the modules that were relevant to my current work.

5. Other _____________

[SKIP TO QUESTION 16]

Please read the following statements and indicate the extent to which you agree or disagree with each.

I feel that this training….

7) Met its objectives.


1. Strongly Agree

2. Somewhat Agree

3. Neither Agree nor Disagree

4. Somewhat Disagree

5. Strongly Disagree

8) Helped me understand the subject matter.

1. Strongly Agree

2. Somewhat Agree

3. Neither Agree nor Disagree

4. Somewhat Disagree

5. Strongly Disagree

9) Had training materials (e.g., readings, slide decks, lectures) that were helpful.


1. Strongly Agree

2. Somewhat Agree

3. Neither Agree nor Disagree

4. Somewhat Disagree

5. Strongly Disagree

10) Covered content that was relevant to the healthcare and health IT industry.


1. Strongly Agree

2. Somewhat Agree

3. Neither Agree nor Disagree

4. Somewhat Disagree

5. Strongly Disagree

11) Covered content that was relevant to my job.


1. Strongly Agree

2. Somewhat Agree

3. Neither Agree nor Disagree

4. Somewhat Disagree

5. Strongly Disagree

12) Kept me actively engaged during the training.



  1. Strongly Agree

  2. Somewhat Agree

  3. Neither Agree Nor Disagree

  4. Somewhat Disagree

  5. Strongly Disagree

13) Had a presenter that effectively demonstrated proficiency in the subject matter.

  1. Strongly Agree

  2. Somewhat Agree

  3. Neither Agree Nor Disagree

  4. Somewhat Disagree

  5. Strongly Disagree

  6. NA-No Instructor


Please answer the following additional questions.

14) The skills I learned in the training will improve my job performance.

1. Strongly Agree

2. Somewhat Agree

3. Neither Agree nor Disagree

4. Somewhat Disagree

5. Strongly Disagree

15) I would recommend this course to others.


1. Strongly Agree

2. Somewhat Agree

3. Neither Agree nor Disagree

4. Somewhat Disagree

5. Strongly Disagree

16) What other training topics would you be interested in learning about?

Open-ended

17) How, if at all, would you recommend that this course be changed to make it more useful to other participants?

Open-ended

Tell us about yourself.

18) Sex

  1. Female

  2. Male

19) Race

  1. American Indian or Alaska Native

  2. Asian

  3. Black or African American

  4. Native Hawaiian or Other Pacific Islander

  5. White


20) Ethnicity

  1. (Hispanic/Latino)

  2. Non-Hispanic/Latino

21) Age

1. 18-24

2. 25-34

3. 35-44

4. 45-54

5. 55-64

6. 65-74

7. 75+


22) Education Level

  1. High school graduate

  2. Some college credit, no degree

  3. Trade/technical/vocational training

  4. Associate degree

  5. Bachelor’s degree

  6. Master’s degree/

  7. Professional degree (e.g. MD, DDS, DVM, LLB, JD)

  8. Doctorate degree (e.g. PhD, EdD)


23) Job Position

      1. Physician(s)

      2. Mid-level Provider

      3. Nurses (RNs and LVNs)

      4. Practice Manager

      5. Medical Assistants

      6. Billing Personnel

      7. Medical Clerk

      8. Other: ______________________

24) What type of facility do you work in?

  1. ACO

  2. Federally Funded Clinic

  3. Federally Funded Hospital

  4. Hospital

  5. Practice

  6. Other:_________________________



5


File Typeapplication/msword
File TitleForm Approved
AuthorDHHS
Last Modified ByWindows User
File Modified2016-04-22
File Created2016-04-22

© 2024 OMB.report | Privacy Policy