End of Wave 2 Feedback Survey

Form Approved OMB No. 0990-XXXX Exp. Date XX/XX/2018

Site Coordinator Feedback on the I Can Do It, You Can Do It! Program

End of Program Wave 2

Thank you for facilitating the I Can Do It, You Can Do It! (ICDI) program for individuals with a disability. You are receiving this questionnaire because you served as the Site Coordinator for an incentivized I Can Do It, You Can Do It! Program.

Please take a few moments to provide us with your feedback regarding technical assistance, program materials, and participation more generally, by responding to the following questions. Feedback from this survey will be kept private to the extent permitted by law. Neither your identity, nor the identity of your site, will be connected to these responses. Results will be used to guide future updates and improvements of the ICDI program. Thank you for your feedback!

Section I: General Program Information

1. What do you think could be done to improve the role of Site Coordinator for an ICDI Program? (Please select all that apply)

• There should be more guidance about how to establish a new program.

• There should be more materials available to facilitate the program.

• There should be more opportunities to connect with other coordinators.

• Other, please specify:

2. What is the one essential thing that we could do to improve the ICDI program in the future?

3. Is there anything additional that you would like to share about your experience in the ICDI program?

Section II: Technical Assistance

4. How often throughout program wave 2 did you proactively reach out for information and support from your Technical Assistance team member?

• Never

• 1-4 times throughout the program

• Weekly

• Multiple times a week

• Daily

5. How often throughout program wave 2 did your Technical Assistance team member proactively reach out to you?

• Never

• 1-4 times throughout the program

• Weekly

• Multiple times a week

• Daily

6. How often did you receive the information and support you needed from your Technical Assistance team member?

• Always

• Most of the time

• About half the time

• Almost never

• Never

7. How would you rate the Technical Assistance team’s level of support throughout the ICDI Program?

• Excellent

• Very good

• Good

• Fair

• Poor

8. What additional support from the Technical Assistance team would have been helpful?

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-XXXX. The time required to complete this information collection is estimated to average 11 minutes per response. 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.