Att 7_Technical Assistance (TA) Satisfaction Instrument

Form Approved

OMB No. 0920-New

Exp. Date: XX/XX/XXXX

Capacity Building Assistance Program: Assessment and Quality Control

Attachment 7

Technical Assistance (TA) Satisfaction Instrument-word version

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

Technical Assistance Satisfaction Instrument

Thank you for participating in a capacity building assistance (CBA) technical assistance event delivered by the Centers for Disease Control and Prevention (CDC) or one of our CBA providers. The Capacity Building Branch of the Division of HIV/AIDS Prevention of the CDC would like to get your feedback on your experience with CBA services. We also want to gather suggestions on how to improve the program. Please be candid in your responses; your comments are extremely important to us and will be used to ensure that the CBA program better meets the needs of our consumers.

Your responses will be kept secure; results will only be shared in aggregate form. Therefore, CBA providers will not know how you, personally, rated their services. Your participation in the assessment is completely voluntary, and failure to participate will not jeopardize your employment or CDC funding of your organization.

On the following pages, you will be asked questions about a specific CBA event. Completing this instrument should take approximately 15 minutes.

Thank you in advance for your time and assistance!

I. Pre-populated Information Generated from CRIS

Unique ID [PRE-POPULATED]

II. Instrument to be completed by respondents

Your Confidential Identifier is the first two letters of your first name (FN), the first two letters of your last name (LN), the month of your birth (MM), and the day of your birth (DD). For example, John Smith, May 29 would be JOSM0529. (NOTE: Your responses are confidential and security measures will be taken to protect your identity).

1. Please enter your Confidential Identifier: __ __ __ __ __ __ __ __

FN FN LN LN M M D D

Below is information about technical assistance that you recently received. In the following questions, we will seek feedback on this specific technical assistance request. Please review the information for accuracy and answer the questions that follow.

[PRE-POPULATED]

Start Date of Technical Assistance Delivery:

End Date of Technical Assistance Delivery:

Service Type:

Request Type:

Delivery Mechanism:

Component:

Content Area:

Behavioral, Structural, or Biomedical Intervention):

CBA Provider:

CBA Request Number:

2. Is the information above accurate?

• Yes (1) [Skip to Question 4]

• No (0) [Go to Question 3]

• Not Sure (88) [Skip to Question 4]

[PRE-POPULATED; Show this information pre-populated again on the same screen as we’re asking the respondent to make corrections. This way, the respondent can easily look back at the pre-populated information while making corrections without having to go back a page in the instrument.]

Start Date of Technical Assistance Delivery:

End Date of Technical Assistance Delivery:

Service Type:

Request Type:

Delivery Mechanism:

Component:

Content Area:

Behavioral, Structural, or Biomedical Intervention:

Venue: CBA Provider:

CBA Request Number:

3. Please correct the information about your TA request below:

3a. Start Date of Technical Assistance Delivery : [TEXT BOX]

3b. End Date of Technical Assistance Delivery: [TEXT BOX]

3c. Service Type [TEXT BOX]

3d. Request Type: [TEXT BOX]

3e. Delivery Mechanism: [TEXT BOX]

3f. Component: [TEXT BOX]

3g. Content Area: [TEXT BOX]

3h. Behavioral, Structural, or Biomedical Intervention: [TEXT BOX]

3i. Venue: [TEXT BOX]3j.CBA Provider: [TEXT BOX]

3k. CBA Request Number: [TEXT BOX]

Delivery of Technical Assistance

4. Please rank your preferred methods of receiving technical assistance.

Rank	Preferred Method
4a. First choice	___Phone ___E-mail ___Online/Web ___In-person/at your agency ___In-person/at a location other than your agency ___Mailing
4b. Second choice	___Phone ___E-mail ___Online/Web ___In-person/at your agency ___In-person/at a location other than your agency ___Mailing
4c. Third choice	___Phone ___E-mail ___Online/Web ___In-person/at your agency ___In-person/at a location other than your agency ___Mailing

TA Expectations, Helpfulness, Utility and Barriers to Implementation

5. What did you expect to gain from the technical assistance? Check all that apply.

• New knowledge and skills [Go to Question 6]

• Opportunities to apply new knowledge and skills [Go to Question 6]

• Basic training [Go to Question 6]

• Advanced training [Go to Question 6]

• TA tailored to my specific needs [Go to Question 6]

• Guidance about which evidence-based intervention would be best for my organization [Go to Question 6]

• Other (please specify): [TEXT BOX] [Go to Question 6]

• I had no expectations [Skip to Question 8]

6. To what extent did the technical assistance meet your expectations?

• Exceeded my expectations (6) [Skip to Question 8]

• Met my expectations (5) [Skip to Question 8]

• Somewhat met my expectations (4) [Go to Question 7]

• Met few of my expectations (3) [Go to Question 7]

• Did not meet my expectations at all (2) [Go to Question 7]

• Other (1) (please specify): [TEXT BOX] [Skip to Question 8]

7. In what way(s) were your expectations NOT met?

[TEXT BOX]

8. Have you used any of the information you gained from the technical assistance?

• Yes (1) [Go to Question 9]

• No (0) [Skip to Question 10]

9. How have you used the information gained from the technical assistance? Check all that apply.

• In day-to-day work with clients

• In outreach, recruitment, or retention efforts

• To refine my organization’s goals and objectives

• To modify my organization’s protocols

• Shared information with coworkers or partner organizations

• Other (please specify): [TEXT BOX]

10. What barriers are preventing you from applying information gained from technical assistance? Check all that apply.

• The information from the technical assistance was not useful

• I am not in a position to use this information as part of my job

• Lack of funding or resources

• Lack of support from managers

• Have not had time to apply

• Have not yet had a need to apply

• Forgot about the TA information received

• Other (please specify): [TEXT BOX]

11. What components of this technical assistance event did you find most helpful?

[TEXT BOX]

12. What would have made the technical assistance you received more useful? Check all that apply.

• More time spent with the technical assistance provider(s)

• TA better tailored to my needs

• More materials and resources provided during technical assistance

• Technical assistance provided through another method (e.g., via email, in person)

• Not sure

• There is no need for improvement

• Other (please specify): [TEXT BOX]

13. What additional training needs do you have related to this topic?

[TEXT BOX]

Satisfaction with Requested Technical Assistance

Please rate the technical assistance provider(s) on the following:

			Neutral
Knowledgeable about subject matter	Not knowledgeable	1	2	3	4	5	Very knowledgeable
Clear communication of information	Not clear	1	2	3	4	5	Very clear
Gave appropriate guidance and suggestions	Not at all appropriate	1	2	3	4	5	Very appropriate
Accessible	Not at all accessible	1	2	3	4	5	Very accessible
Responsive to questions	Not responsive	1	2	3	4	5	Very responsive
Took into consideration the cultural background of the people served by my organization	Did not take into account at all	1	2	3	4	5	Very much took into account
Overall effectiveness	Not effective	1	2	3	4	5	Very effective

Please rate the technical assistance content and materials on the following:

			Neutral
Content tailored to me	Not at all tailored	1	2	3	4	5	Very tailored
Usefulness of materials	Not at all useful	1	2	3	4	5	Very useful
Relevance of materials to me	Not at all relevant	1	2	3	4	5	Very relevant
Overall usefulness of TA	Not at all useful	1	2	3	4	5	Very useful
Overall relevance of TA to me	Not relevant	1	2	3	4	5	Very relevant
Overall effectiveness	Not effective	1	2	3	4	5	Very effective

Please rate the technical assistance in the following areas:

Just right

TA length	Much too long	1	2	3	4	5	Much too short
TA complexity	Much too basic	1	2	3	4	5	Much too complex

29. To what extent did the technical assistance meet your needs?

• More than met my needs (5) [Skip to Question 31]

• Met my needs (4) [Skip to Question 31]

• Somewhat met my needs (3) [Go to Question 30]

• Met few of my needs (2) [Go to Question 30]

• Did not meet my needs at all (1) [Go to Question 30]

30. In what ways were your needs NOT met?

[TEXT BOX]

31. If the need arises, how likely is it that you will be interested in working with this CBA provider again?

• Very likely (5)

• Likely (4)

• Somewhat likely (3)

• Not likely (2)

• Not at all likely (1)

• Not sure (88)

Overall Satisfaction with Requested Technical Assistance

32. Overall, how satisfied are you with the technical assistance you received?

• Very satisfied (5)

• Satisfied (4)

• Somewhat satisfied (3)

• Not very satisfied (2)

• Not at all satisfied (1)

Please rate the level of importance of the following aspects of technical assistance in determining your overall level of satisfaction with the technical assistance.

Not at all Neutral Very

important important

Quality of content/materials	1	2	3	4	5
Quality of technical assistance provider	1	2	3	4	5
Technical assistance delivery method	1	2	3	4	5
Match of technical assistance with your needs	1	2	3	4	5
The relevance of the technical assistance content to your/your organization’s needs	1	2	3	4	5
The technical assistance’s emphasis on the most important information	1	2	3	4	5
The extent to which the technical assistance prepared you to perform newly learned skills?	1	2	3	4	5
Other (please specify): [TEXT BOX]	1	2	3	4	5

Participant Information

33. How many years of professional experience do you have in the field of HIV prevention?

______ years [TEXT BOX; 2 digits]

THANK YOU