Form 1 F2F HIC DataSubmission_Form

Family-to-Family Health Information Center (F2F HIC) Feedback Surveys

DataSubmission_Form

Family-to-Family Health Information Centers Data Submission Form

OMB: 0906-0040

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OMB No: 0906-XXXX

Expiration Date: XX/XX/XXXX




Sample F2F HIC Survey Data Log



S = screener questions included at the beginning of each survey.

Q = corresponds to the feedback survey question.

Excel Tab 1: Families

Respondent Identifier

Response Type

Response date

S1

S1.1

S2

S3

S4

S5

S6

S6.1

S7

Q1

Q2

Q3

Q4

*Average Feedback Score

SMI245

Family

2/2/17

1

CP

1

0

0

0

0

N/A

0

4

4

4

1

3.25

MUR010

Family

2/7/17

0

N/A

1

0

0

1

1

N/A

0

4

3

3

4

3.5

Totals



1


2

0

0

1

1


0

8

7

7

5



Excel Tab 2: Professionals

Respondent Identifier

Response Type

Response date

S1

S2

S3

S4

S5

S6

S6.1

S7

Q1

Q2

Q3

Q4

*Average Feedback Score

DIA007

Professional

2/6/17

0

1

0

1

0

1

IEP

0

3

3

3

2

2.75

KRA874

Professional

2/10/17

1

1

1

1

1

0

N/A

0

4

4

4

4

4

Totals



1

2

1

2

1

1


0

7

7

7

6



Excel Tab 3: Training Participants

Respondent Identifier

Response Type

Response date

S1

S2

Q1

Q2

Q3

Q4

*Average Feedback Score

ABC321

Trainee

2/10/17

0

1

2

1

4

3

2.5

LPS041

Trainee

2/10/17

1

0

N/A

N/A

N/A

N/A


Totals



1

1

2

1

4

3



* The average feedback score for each survey = total score from all feedback survey questions (Q) / four (4) questions.


HRSA may choose to report on a specific question. For example, 90% of families who responded to the F2F HIC feedback survey reported they would recommend the F2F to other families or professionals.



Public Burden Statement: 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 control number for this project is 0906-xxxx. Public reporting burden for this collection of information is estimated to average xx hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857.


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorZerislassie, Tigisty (HRSA)
File Modified0000-00-00
File Created2021-01-15

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