Form 1 Tailored Services Satisfaction Survey

OMB Control No.: xxxx-xxxx

Expiration Date: xx/xx/20xx

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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.

Tailored Services Satisfaction Survey

Administration Guidelines for Cross-Center Evaluation: These items will be administered as part of the Capacity Survey. The satisfaction items for tailored services will only be included on the Capacity Survey on the annual administration of the survey for projects lasting more than one year and on the final administration of the Capacity Survey at completion of the tailored service. For tailored services that last less than one year, the satisfaction items will only be included on the final administration of the Capacity Survey at completion of the tailored service. Center evaluators are encouraged to incorporate these items into Center-specific data collection tools as appropriate.

Domains Assessed:

• Liaison/Consultant Expertise

• Culturally Responsive & Respectful (Liaisons & Consultants)

• Usefulness

• Adaptable

• Endorsement

• General Satisfaction

Please answer the following questions about your experiences with your tailored service.	Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree
Liaison/Consultant Expertise
As a group, the representatives from the Center(s) had the right level of subject-matter knowledge and expertise.
As a group, the representatives from the Center(s) had the skills to effectively guide the tailored service.
As a group, the representatives from the Center(s) facilitated a collaborative process for implementing our plan.
Culturally Responsive & Respectful
As a group, the representatives from the Center(s) were a good match for helping us build our program capacity.
As a group, the representatives from the Center(s) had a good understanding of our agency/community needs.
As a group, the representatives from the Center(s) communicated with us in a way that felt relevant to the values and context of our agency/tribe/court.
Our ideas and desires about the tailored service process were respected by Center representatives.
Usefulness
The Center(s) provided effective support for our agency/tribe/court throughout the service delivery process.
The materials and information were appropriate for our agency/tribe/court’s level of experience and knowledge.
Our agency/tribe/court’s knowledge and/or skills about the topic(s) addressed by the tailored service have increased.
The knowledge and skills our agency/tribe/court acquired through this tailored service are directly applicable to our work.
Adaptable
The Center(s) helped us to identify and set milestones and measurable outcomes to track progress and success.
The Center(s) helped us to use data to make adjustments to the intervention and/or implementation process as needed.
My agency/tribe/court is considering using a similar change process/implementation framework in other initiatives.
Endorsement
I would recommend working with Center(s) to other jurisdictions.
I will share what I learned during my experience with the Center(s) with others.

SKIP PATTERN: If Somewhat Agree, Agree, or Strongly Agree are selected for item above ask:

If so, how and with what groups of colleagues will you share what you learned?

__________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________

SKIP PATTERN: If Neither Agree nor Disagree, Somewhat Disagree, Disagree, or Strongly Disagree are selected for item above ask:

If not, why not?

__________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________

General Satisfaction
The services provided met the needs of our agency/tribe/court.
Overall, I was satisfied with the services I received.

General Satisfaction (Cont.)

Could your experience with the Center(s) have been improved? (Circle One)

YES NO

If yes, please describe how your experience with the Center(s) could have been improved.

__________________________________________________________________________________________________________________________________________________________________________________________

Capacity Building Process

Domains Assessed:

• Transferability

• Cultural Fit

• Liaison/Consultant Effectiveness

• General Satisfaction

Please answer the following questions about the capacity building process.	Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree
Transferability
The steps in the capacity building process (assessment, planning and design, service delivery and monitoring, etc.) were clearly communicated to our staff and stakeholders.
This capacity building process may be a useful tool for us to apply during other systems change initiatives.
Cultural Fit
This capacity building process was flexible to meet the needs of our agency/tribe/court.
Our agency/tribe/court’s values and practices were respected during the capacity building process.
In general, this process reflected how people from our agency/tribe/court work together to accomplish something.
The steps in the capacity building process are appropriate for the systems change work we are doing.
Liaison/Consultant Effectiveness
As a group, the representatives from the Center(s) effectively guided us through capacity building process.
As a group, the representatives from the Center(s) helped us to identify readiness and possible barriers to the plan that must be addressed.
Our agency/tribe/court was able to develop a strong plan with measureable goals with the support of the Center representatives.
As a group, the representatives from the Center(s) communicated with us in a way that felt relevant to the values and context of our agency/tribe/court.
	Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree
General Satisfaction
Overall, I was satisfied with the capacity building process.