Web Assessment - word version

Form Approved

OMB No. 0920-1027

Expiration Date: 07/31/2020

Collecting Customer Feedback from CDC-Funded Community Based Organizations about Rapid Feedback Reports

Attachment # 1

Web Assessment to Accompany CBO RFRs

Privacy Act Statement:

This information is collected under the authority of the Public Health Service Act, Section 301, "Research and Investigation," (42 U.S.C. 241); and Sections 304, 306 and 308(d) which discuss authority to maintain data and provide assurances of confidentiality for health research and related activities (42 U.S.C. 242 b, k, and m(d)). This information is also being collected in conjunction with the provisions of the Government Paperwork Elimination Act and the Paperwork Reduction Act (PRA). This information will only be used by the Centers for Disease Control and Prevention (CDC) staff to evaluate the Rapid Feedback Reports.

Public reporting burden of this collection of information is estimated to average 5 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 (0920-1027)

Instructions:

We invite you to complete an assessment based on your experience with the Rapid Feedback Report (RFR). Your feedback will help us enhance the value of these reports to you and your organization (e.g., program improvement). Your participation in this assessment is completely voluntary. It should take no more than 5 minutes to complete.

1. Did you read this RFR?

• Yes

• No

2. If no, why not?

3. Have you read previous RFRs?

• Yes

• No

4. If no, why not?

5. At your agency, with whom do you share the RFR? (check all that apply)

• I do not share the RFR with others at my agency

• Executive Director

• Program Manager

• Program Evaluator

• HIV Testing Coordinators

• Other program staff. Please specify program staff position or role: _______________________

6. How do you or your agency staff use the RFR? (check all that apply)

• Program improvement

• Monitor program progress

• Set program goals

• Compare my agency’s progress to other agencies

• We do not currently use the RFR

• Other. Please specify: __________________________

7. The RFR currently has three indicators (HIV tests, newly diagnosed HIV-positive persons, and linkage to care for newly diagnosed HIV-positive persons). How satisfied are you with the indicators presented in the RFR?

• Very satisfied

• Somewhat satisfied

• Neither satisfied nor dissatisfied

• Somewhat dissatisfied

• Very dissatisfied

8. If additional indicators are added, which of the following would you like to see added? (check all that apply)

• Previously identified HIV-positive persons

• Risk information for HIV-negative persons

• Demographic information

• Referrals

• Other. Please specify: ____________________

9. How easy to interpret are the graphs and descriptions presented in the report?

• Extremely clear

• Somewhat clear

• Not very clear

• Not at all clear

10. How useful are the graphs showing comparisons between your agency and other agencies?

• Extremely useful

• Somewhat useful

• Not very useful

• Not at all useful

11. How useful are the data tables at the end of the report?

• Extremely useful

• Somewhat useful

• Not very useful

• Not at all useful

12. If you would like to share additional comments, questions or experiences about the RFR, please enter them below: