Form 1 Infant Toddler Specialist Individualized Technical Assis

I TSN Feedback Form

Tailored/Individualized TA

TITLE OF INFORMATION COLLECTION: State Capacity Building Center Targeted Technical Assistance Feedback Collection for Infant Toddler Specialist Individualized Technical Assistance

OMB Control No: 0970-0401

Expiration date: 05/31/2021

Instructions

The State Capacity Building Center is collecting feedback regarding its technical assistance (TA) services provided to your state by the Infant/Toddler specialist. We would greatly appreciate your voluntary, anonymous input. We will use your feedback to inform and improve the work of the Infant Toddler Specialists of the State Capacity Building Center.

To provide feedback, please respond using this form. The survey will only take a few minutes and all responses are anonymous.

NOTE: THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13). Public reporting burden for this collection of information is estimated to average 8 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.

Responsiveness

	Strongly Agree	Agree	Disagree	Strongly Disagree	Not Applicable
The Infant/Toddler Specialist is responsive to our needs.	1	2	3	4	N/A
The Infant/Toddler Specialist has helped us to solve problems.	1	2	3	4	N/A

If you marked disagree or strongly disagree above or if you have any comments, please take a moment to give us a little more information.

Quality of Products and Services

	Strongly Agree	Agree	Disagree	Strongly Disagree	Not Applicable
The Infant/Toddler Specialist has provided the services and/or products we requested.	1	2	3	4	N/A
The products and/or services are of high quality.	1	2	3	4	N/A

If you marked disagree or strongly disagree above or if you have any comments, please take a moment to give us a little more information.

Quality of Infant/Toddler Specialists

	Strongly Agree	Agree	Disagree	Strongly Disagree	Not Applicable
We are satisfied with the Infant/Toddler Specialist’s approach to working with our team.	1	2	3	4	N/A
The Infant/Toddler Specialist has the experience, knowledge, and ability to support our TA request.	1	2	3	4	N/A
The Infant/Toddler Specialist understands our state context and culture.	1	2	3	4	N/A

If you marked disagree or strongly disagree above or if you have any comments, please take a moment to give us a little more information.

Work with the Infant/Toddler Specialists Related to Project Planning, Coordination, and Implementation

	Strongly Agree	Agree	Disagree	Strongly Disagree	Not Applicable
Helped us identify priorities and clear action steps for our TA request.	1	2	3	4	N/A
Suggested strategic next steps and/or helped us begin to implement improved strategies.	1	2	3	4	N/A
Connected us to resources (internal or external) that will help us more easily access answers/ solutions in the future.	1	2	3	4	N/A
Influenced our overall approach to our project.	1	2	3	4	N/A

If you marked disagree or strongly disagree above or if you have any comments, please take a moment to give us a little more information.

What factors if any, may prevent you from using what you learned in your work? (Please check ALL that apply)

□ What I’ve learned is not applicable to my work

□ Lack of time

□ Limited funds or other resources to support this effort

□ Lack of state policies or processes to support this effort

□ Lack of support/guidance from state leadership

□ Limited or no stakeholder buy-in

□ I don’t have the authority or influence to gain support for this effort

□ Other (Please describe):______________

Which aspect(s) was most useful for you and why?

How could we improve this work to better meet your needs?

What other topics for technical assistance would be useful to you?

Thank you for participating and we hope the content provided met your expectations

Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to collect participant feedback to shape future OCC technical assistance services. Public reporting burden for this collection of information is estimated to average 8 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. The OMB number and expiration date for this collection are OMB #:. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to J.R. Sayoc or [email protected].

November 2017 1