1:
			 Service Utilization by Type of Organization Requesting Service
			and Outcomes for Reporting Period  
			 
			Category 
			
				Total
				number of individual clients/departments requesting TRC services
				and hours of client contact service provided, including
				preparation time. 
				Total
				number of new/first time 
				Total
				number of repeat clients (those who received service in the past
				– prior to the  current reporting period – who are
				returning for more/other services) 
				Total
				number of hours of technical assistance provided including
				preparation time 
			 
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			1:
			 Service Utilization by State and Type of Organization Requesting
			Service 
			 
			 
			 
			Service
			Utilization 
			 
			
			 
			 
			Type
			of Organization Requesting Service 
			
				Academic
				Institution/School 
				 
				Associations/Organizations
				(National, State or Regional) 
				 
				
				Clinic 
				
				Funders
				(Foundations/Health Plans) 
				Hospital/Health
				System 
				 
				
					Critical
					Access Hospital (CAH) (25 beds or less) 
					Small
					Rural Hospital (50 beds or less) 
					 
					
					Health
					Resources and Services Administration (HRSA) Grant Funded Entity 
					Government
					Agency (Federal, State, Regional or Local) 
					
				 
			 
			Tribal/IHS 
			
				
					
					Legislator/Policy
					Maker /staffer(or office) 
					Telehealth
					Resource Center 
					 
					Vendor 
					
					Other
					(list other and provide total numbers) 
					 
				 
			 
			 
			 
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			2:
			 Method of Query for Reporting Period 
			Category 
			
			
				Email 
				Phone 
				Referral
				from Another TRC 
				Social
				Media (Twitter, Facebook, LinkedIn, etc.) 
				TRC
				Initiated 
				Website 
				Other 
			 
			 
			 
		 | 
		
			2:
			 TRC Technical Assistance Communication Method of Inquiry and
			Response 
			 
			 
			 
			Method
			of Technical Assistance Inquiry 
			 
			
			
				Phone
				
				 
				In-Person
				Contact at an event (ie. training, conference, meeting, other) 
				TRC
				Website Form 
				 
				Referral
				from Another TRC 
				 
				Social
				Media (Twitter, Facebook, LinkedIn, etc.) 
				TRC
				Initiated 
				Other
				
				 
			 
			 
			 
			Method
			Used to Respond to Inquiries 
			 
			
				Email
				
				 
				Phone
				
				 
				Videoconference
				
				 
				In
				Person Visit 
				Other 
			 
			 
			 
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			3:
			 Topic of Query for Reporting Period 
			Category 
			
				General
				Information 
				Clinical
				Service Program Development/Operations 
				Equipment
				and Technology Assessment/Selection 
				Financial
				(Reimbursement, Business Models, Grants) 
				Policy 
				Other 
			 
			 
			 
		 | 
		
			3:
			 Topic of Inquiry 
			 
			Category 
			
				Financial
				(Reimbursement, Business Models, Grants) 
				 
				Policy/Legal
				 
				 
				Market
				Analysis 
				 
				About
				my TRC 
				 
				Broadband
				network infrastructure  
				 
				Readiness
				Assessment 
				 
				Distance
				Learning 
				
				Program
				Evaluation 
				 
				Strategic
				Planning 
				 
				Tools
				and Templates 
				General
				Telehealth Information 
				Clinical
				Service Program Development/Operations 
				 
				
				Equipment
				and Technology Assessment/Selection 
				 
				Other 
			 
			 
			 
		 | 
	
	
		
			4:
			 Types of Services Provided by TRC during the Reporting Period 
			Category 
			Training/Education
			and Outreach 
			Events 
			
				Organize/Host
				Conference or Training Event (# of Events, Total Direct Service
				Hours, Total # of Participants)  
				 
				Presentation
				at Conferences/Meetings/Webinars (# of Presentations, Total
				Direct Service Hours, Total # of Participants) 
				Other 
			 
			Communications/Promotional
			Activities 
			
				Exhibits
				(# of hours, # of contacts) 
				Newsletter
				(# of  newsletters, # of subscribers) 
				Web
				Site (# unique visitors, # of pages viewed by visitors) 
				Research
				Publications (# of publications) 
				General
				Media (# interviews/articles) 
			 
			Social
			Media 
			
				Facebook
				(# of page likes, # of posts) 
				Twitter
				(# of followers, # of tweets) 
				LinkedIn
				(# of followers, # of posts) 
			 
			Other 
			Technical
			Assistance/Consultation 
			Method
			Used to Respond to Queries 
			
				Email
				(# responses) 
				Phone
				(# responses) 
				Videoconference
				(# responses) 
				In
				Person Visit  (# responses) 
				Group
				Collaboration/Planning (# responses) 
			 
			Client
			Satisfaction Survey Results 
			The
			following 4 questions come from the standardized Client
			Satisfaction Questionnaire – CSQ-8 and ratings are on a 4
			point scale) 
			
				How
				would you rate the quality of service you received –
				Excellent, Good, Fair, Poor  (# respondents, average rating) 
				If
				a colleague were in need of similar help, would you recommend our
				program to him or her – No, definitely not, No, I don’t
				think so, Yes, I think so, Yes definitely  (# respondents,
				average rating) 
				In
				an overall, general sense, how satisfied are you with the
				services you have received – Very satisfied, Mostly
				satisfied, Indifferent or mildly dissatisfied, Quite dissatisfied
				  (# respondents, average rating) 
				If
				you were to seek help again, would you come back to our program –
				 No, definitely not, No, I don’t think so, Yes, I think so,
				Yes, definitely         (# respondents, average rating) 
				Tools/Materials/Resources
				(# developed, # distributed) 
			 
			 
			 
		 | 
		
			4:
			 Types of Services Provided by TRC  
			 
			 
			 
			Training/Education
			and Outreach 
			 
			
			 
			 
			Communications/Promotional
			Activities 
			 
			
			 
			 
			Tools/Materials/Resources
			
			 
			
			 
			 
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