Pilot Feedback Form

NHTTAC Consultant and Evaluation Package

21 - Pilot Feedback

Pilot Feedback Form

OMB: 0970-0519

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0970-0519 can be found here:

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PILOT FEEDBACK

OMB Control Number: 0970-0519
Expiration Date: 10/31/2021

Form

In order to help the National Human Trafficking Training and Technical Assistance Center (NHTTAC) better serve the field, we
are reaching out to obtain your feedback. We will protect the privacy of your information in accordance with the Federal Privacy
Act, and we will protect the confidentiality of your responses using procedures we have in place, including reporting all
information in aggregate to avoid identifying information. Only members of the NHTTAC Evaluation Team have access to
information that could identify respondents. If you have any questions about this survey or the evaluation, please contact
[email protected].
TRAINING:
DATE(S):
CONSULTANT(S)/PRESENTER(S):

Please provide the information below to create an anonymous ID:

____________

______________

Birth Month

First letter of first name

First letter of your middle name

(insert just the month

(example: S for Sara)

(example: M for Maria)

for your date of birth:
08 for August)
Please indicate the extent to which you agree or disagree with the following statements:

OVERALL TRAINING
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

11.
12.
13.
14.

The training addressed the learning objectives clearly.
The training addressed the critical issues related to the
topic(s).
The time allotted was adequate for the scope of material
covered.
The training was well organized and clear.
The [material] [strategic planning] was appropriate for my
level of experience and knowledge.
The resource materials (handouts, audiovisuals,
PowerPoints) enhanced the training.
The training increased my knowledge related to the topic(s).
The training increased my practical skills related to the
topic(s).
I will be able to apply what I learned in my work.
The training improved my ability to identify people who are
being trafficked, at-risk of trafficking, or have been
trafficked.
The training was survivor informed.
The training provided sufficient opportunity to network with
others in the field.
The training was trauma informed.
The training content was based on current evidence-based
research or promising practices.

Strongly
Disagree

Disagree

Agree

Strongly
Agree

Not
Applicable

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid OMB control
number. The estimated average time to complete this form is 9 minutes. If you have comments regarding the accuracy of this estimate or
additional suggestions, please write to the NHTTAC Evaluation Team at [email protected] or 9300 Lee Highway, Fairfax, VA 22031.

PILOT FEEDBACK

OMB Control Number: 0970-0519
Expiration Date: 10/31/2021

Form

15.
16.
17.
18.
19.

The small group activities enhanced my experience.
The training met my professional needs.
The training met my educational needs.
I am satisfied with the overall quality of the training.
The training was grounded in a multidisciplinary approach to
addressing human trafficking.

1
1
1
1

2
2
2
2

3
3
3
3

4
4
4
4

NA
NA
NA
NA

Please indicate the extent to which you agree or disagree with the following statements:

MODULE : ____________________________
20.
21.
22.
23.
24.

Disagree

Agree

Strongly
Agree

Not Applicable

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

4
4
4
4
4

NA
NA
NA
NA
NA

Strongly
Disagree

Disagree

Agree

Strongly
Agree

Not Applicable

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

4
4
4
4
4

NA
NA
NA
NA
NA

As a result of this module, I can .
As a result of this module, I can .
As a result of this module, I can .
As a result of this module, I can .
The learning objectives for this module were stated clearly.

MODULE : ____________________________
25.
26.
27.
28.
29.

Strongly
Disagree

30. Please rate the overall quality of this training.
1

Poor

Fair

Good

Excellent

Please indicate the extent to which you agree or disagree with the following statements:

PRESENTER 1:___________________________
31. The presenter demonstrated a comprehensive knowledge of
the subject.
32. The presenter presented the content clearly and logically.
33. The presenter responded positively to questions and
comments.
34. The presenter created a respectful environment for
participants.

PRESENTER 2:___________________________
35. The presenter demonstrated a comprehensive knowledge of
the subject.
36. The presenter presented the content clearly and logically.
37. The presenter responded positively to questions and
comments.

Strongly
Disagree

Disagree

Agree

Strongly
Agree

Not
Applicable

Strongly
Disagree

Disagree

Agree

Strongly
Agree

Not
Applicable

PILOT FEEDBACK

OMB Control Number: 0970-0519
Expiration Date: 10/31/2021

Form

38. The presenter created a respectful environment for
participants.

39. Did the training provide comprehensive coverage of the topic(s)? Please explain.

____________________________________________________________________________________
____________________________________________________________________________________
42. Was there anything you would change about the resource materials (videos, handouts, PowerPoints, etc.)? Please explain.

____________________________________________________________________________________
____________________________________________________________________________________
48. Which of the following best describes the organization in which you work? (Mark all that apply.)
Academic institution
Anti-trafficking organization
Business/For-profit organization
Coalition/Multidisciplinary team/Task force
Federal government
Faith-based organization
State and local government
Nonprofit/Community-based organization

OTIP grantee
Self-employed
Survivor-led organization
Tribal government
Union/Worker advocacy organization
Victim service provider
Other (please specify): _____________________

PILOT FEEDBACK

OMB Control Number: 0970-0519
Expiration Date: 10/31/2021

Form

49. Is your organization responsible for working with people who are currently being trafficked or have been trafficked?
□ Yes
□ No
50. Which of the following best describes your professional capacity or types of services you provide? (Mark all that apply.)
Behavioral health professional (e.g., psychologist,
Legal (e.g., immigration, civil and/or rights-based
psychiatrist, mental health/substance use counselor)
attorney and/or paralegal, clinic)
Child welfare (e.g., state agency staff, child welfare
Public health (e.g., licensure board, health
contractor, nonprofit personnel)
department staff, health care executive, community
health workers)
Corrections-based services (e.g., parole, probation)
Social worker (e.g., case manager, school
Criminal justice (e.g., law enforcement, prosecutor,
counselor, supervisor, administrator)
probation, court, forensic interviewer)
Survivor empowerment, mentoring, or peer to peer
Educator (e.g., teacher, professor, school
administrator)
Violence prevention (e.g., child abuse and neglect,
elder abuse, domestic violence, sexual violence,
Health care (e.g., physician, physician assistant,
youth violence)
nurse practitioner, dentist, nurse, pharmacist)
Other (please specify):
Housing (e.g., case worker, shelter director, public
_______________________________
housing authority agencies)
51. In your professional capacity, how frequently do you come into contact with a person who is being trafficked, at risk of
being trafficked, or has been trafficked?
1

Never

Occasionally

Frequently

Daily

52. Which of the following best describes the number of years of experience you have in your current field of work?
□

Less than 3 years

□ 3–5 years

□

□ More than 10 years

6–10 years

53. Which of the following best describes your primary role in your current position?
□ Direct delivery/Frontline staff
□ Management
□ Other (please specify): _______________

□ Consultant/Trainer
□ Volunteer

□ Administration
□ Peer educator

54. Which of the following best describes your geographic population? (Mark all that apply.)
□ National
□ State (please specify): ______________
□ Tribal
□ International (please specify country): _______________

□

Local
□ Urban
□ Rural
□ Suburban

55. Please select any of the following populations you currently work with in a professional capacity (Mark all that apply.)
Human trafficking
Commercial sexual exploitation of
children
Sex trafficking
Adults
Minors
Labor trafficking
Adults

Minors
Children/youth
Out of home/Foster care/Kinship care
Juvenile justice
Runaway/Homeless youth
People with disabilities
Deaf/Hearing impaired
Elderly

PILOT FEEDBACK

OMB Control Number: 0970-0519
Expiration Date: 10/31/2021

Form

Lesbian, gay, bisexual, transgender, and
questioning
Foreign nationals (migrant workers, undocumented
immigrants, refugees)
People with low incomes
Racial and ethnic minorities
American Indian or Alaska Native
Asian
Black or African American

Native Hawaii or other Pacific Islander
White
Hispanic or Latino ethnicity
History of substance use
Intimate partner violence (e.g., dating, domestic
violence)
Gang-related crime
Sexual abuse/Violence
Other (please specify): __________________

56. What is your race? (Mark all that apply.)







American Indian or Alaska Native
Asian
Black or African American
Native Hawaii or other Pacific Islander
White
Other (please specify): _______________________________________

57. What is your ethnicity? (Mark all that apply.)




Hispanic or Latino
Middle Eastern or North African
Other (please specify): ________________________________________

58. What is your gender? (Mark all that apply.)





Male
Female
Transgender
Other (please specify): ________________________________________

Thank you for taking the time to complete this form and helping to improve NHTTAC/SOAR activities.

File Type	application/pdf
Author	Field, Michael
File Modified	2019-11-01
File Created	2019-11-01