Form Technical Assistan Technical Assistan Technical Assistance Follow-up Form

Attachment D: Technical Assistance Follow-up Form

OMB No. 0930-0xxx

Expiration Date:  xx/xx/xx

 

 

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 0930-0xxx.  Public reporting burden for this collection of information is estimated to average 60 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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 SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

INITIAL EMAIL

Dear <first name> <last name>,

Our records indicate that a couple of months ago you participated in technical assistance delivered/supported by the Center of Excellence for the Infant and Early Childhood Mental Health Consultation (IECMHC) initiative.

At the Center of Excellence, we are continually working to improve our services. To that end, we would like your feedback on the recent technical assistance that your organization received from <Primary TA Provider> (and perhaps other individuals from the Center of Excellence) concerning <Text for Followup>. Our records indicate that this particular service involved, but was not limited to, support with:

<Bulleted list of services provided over the course of this TA>

The process involves answering only a few short questions. Click on the link below and a new browser window should open. If the link is not highlighted, or if a new window does not open when you click on the link, simply copy and paste the address into the location bar of your browser’s window.

Click on this link to begin the feedback survey:

<link to feedback survey>

If you would prefer not to participate, click on the link below:

<link to opt-out page>

Thank you in advance for your cooperation. If you have any questions about this process, you can contact the Center of Excellence Evaluator <Name of Center of Excellence Lead Evaluator> at <Email Address of Center of Excellence Lead Evaluator>.

TECHNICAL ASSISTANCE FOLLOW-UP FORM

Thank you for agreeing to provide us with feedback on the recent technical assistance service delivered by the Center of Excellence TA provider described in the feedback invitation. We ask that you limit your responses only to that particular service.

1. How useful has this technical assistance been to your organization’s mental health consultation work? (Choose one response, and include any comments you may have.)
   <Not at All Useful, Not Very Useful, Somewhat Useful, Very Useful><box for open-ended responses>
   If respondent answers Somewhat Useful or Very Useful, skip to Question 3.

2. What elements not incorporated into the technical assistance would you like to see addressed?
   <box for open-ended responses>

3. To what extent has this technical assistance improved your organization’s capacity to implement mental health consultation work? (Choose one response, and include any comments you may have.)
   <Not at All, Not Very Much, Somewhat, A Great Deal><box for open-ended responses>

4. Please provide an example of how you and/or your organization have been able to apply the information, ideas, or skills delivered through this technical assistance service.
   <box for open-ended responses>

5. Feel free to provide any additional comments or suggestions about this service, including how future assistance could be improved.
   <box for open-ended responses>

We are required to collect demographic information on recipients of this service. Your responses will remain private and will only be reported in aggregate with those of other participants.

6. Which of the following best describes you in terms of Hispanic or Latino heritage? (Choose one.)

• Hispanic/Latino

• Not Hispanic/Latino

• I prefer not to answer

7. Which of the following best describes you in terms of race/ethnicity? (Choose all that apply.)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Pacific Islander

• White

• I prefer not to answer

Thank you for your feedback. Click on the button below to submit your response.

FINAL EMAIL

Dear <first name> <last name>,

Our records indicate that a couple of months ago you participated in technical assistance delivered/supported by the Infant and Early Childhood Mental Health Consultation (IECMHC) Center of Excellence.

At the Center of Excellence, we are continually working to improve our services. To that end, we would like your feedback on the recent technical assistance that your organization received from <Primary TA Provider> (and perhaps other individuals from the IECMHC) concerning <Text for Followup>. Our records indicate that this particular service involved, but was not limited to, support with:

<Bulleted list of services provided over the course of this TA>

We will be closing access to this feedback form very soon. Can you please reply by <survey closing date>?

The process involves answering only a few short questions. Click on the link below and a new browser window should open. If the link is not highlighted, or if a new window does not open when you click on the link, simply copy and paste the address into the location bar of your browser’s window.

Click on this link to begin the feedback survey:

<link to feedback survey>

If you would prefer not to participate, click on the link below:

<link to opt-out page>

Thank you in advance for your cooperation. If you have any questions about this process, you can contact Center of Excellence Evaluator <Name of Center of Excellence Lead Evaluator> at <Email Address of Center of Excellence Lead Evaluator>.