Opioid Care Coordination Consultation Meetings Feedback

Form Approved

OMB No. 0990-0459 Exp. Date XX/XX/20XX

Participant Feedback Form

HHS Office on Women’s Health and Health Resources and Services Administration Office of Women’s Health Regional Opioid Consultation Initiative

Regional Consultation Meeting | Rockville, Maryland | Tuesday, February 5, 2019

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Thank you for participating in the Women’s Health Regional Opioid Consultation Meeting. In order to help us evaluate this meeting and improve similar meetings, we ask you to answer the following questions. Your completion of this form is completely voluntary and your responses are confidential. By completing the form you are giving your consent to participate in this assessment.

For each of the following statements, please circle a number indicating your level of agreement.

	Strongly Disagree		Disagree		Neither Agree Nor Disagree		Agree		Strongly Agree
Meeting facilitators actively welcomed all perspectives in discussion.		1		2		3		4		5
Meeting facilitators prepared me to make meaningful contributions during the meeting.		1		2		3		4		5
The meeting provided sufficient time for discussion.		1		2		3		4		5
The meeting was well organized and structured.		1		2		3		4		5
Overall, most meeting attendees exhibited the expertise needed to address care coordination for women with opioid use disorder in HRSA care settings		1		2		3		4		5
Meeting attendees represented regional stakeholders and decision-makers on opioid use disorder issues for women.		1		2		3		4		5
I clearly understood my role (and tasks) in the meeting.		1		2		3		4		5
I was actively engaged in all aspects of the meeting.		1		2		3		4		5
Overall, attendees were engaged in the meeting and its discussions.		1		2		3		4		5
I understand how information from this meeting will be used to inform a Care Coordination Model.		1		2		3		4		5
The meeting was successful in identifying promising practices, innovations, and recommendations that will be useful in a Care Coordination Model.		1		2		3		4		5
I was satisfied with this meeting overall.		1		2		3		4		5

Below we ask open-ended questions, and invite you to please write your responses in the space provided.

1. What was the most valuable part of the meeting for you?

2. What would you change or improve about the meeting?

3. Do you think this meeting helped promote action to develop a care coordination model? Why or why not?

4. Please share below anything that you did not have the opportunity to share during the meeting.

Thank you for completing this form!

**Please continue on to Side 2 of this form**

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 0990-0459. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete 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