Form A Attachment A-Annual Satisfaction Survey

OMB No: 0915-0212

Expiration date: 07/31/2021

HV-ImpACT Annual Survey

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 0915-0212. Public reporting burden for this collection of information is estimated to average .08 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.

1. HV-ImpACT is conducting a satisfaction survey to gather information about your experiences with the technical assistance received over the past 12 months. HV-ImpACT will not penalize or reward you based on your responses to this survey. It will take you approximately 3-5 minutes to complete the survey.

 

The information you provide will help us make improvements to future technical assistance activities. Your responses to the survey are strictly confidential. Your individual responses will not be reported.

 

Completing the survey is voluntary. If you have questions about this project, please contact Emma McAuley at [email protected]. We sincerely appreciate your time and willingness to participate.

 

By clicking "I agree" below you are indicating that you have read and understood this consent form and agree to participate in this survey. You may print a copy of this page for your records.

• I agree

• I do not agree [If selected, respondent skipped to end of survey]

2. What is your state/territory?

   1. Drop down list of all 56 states & territories, plus an N/A option

3. HV-ImpACT offered a range of technical assistance products and services in 2018, including webinars, newsletters, Communities of Practice, and individualized assistance with a TA Specialist.

Please select all technical assistance that you have accessed in the past year. Check all that apply.

• Awardee Model Developer Webinar Dialogue

• Community of Practice

• Home Visiting Home Run newsletter

• Home Visiting Issues and Insights issue brief & written resources

• MIECHV Awardee Portal (MAP)

• Peer to Peer Learning Dialogue

• Targeted or individualized assistance from a TA Specialist

• Webinar

• None of the above [If selected, respondent skipped to end of survey]

4. Overall, how helpful was HV-ImpACT’s technical assistance in addressing your TA needs this year?

• Extremely helpful

• Very helpful

• Moderately helpful

• Slightly helpful

• Not at all helpful

5. [If respondent chooses “Moderately helpful,” “Slightly helpful,” or “Not at all helpful”] How could HV-ImpACT’s technical assistance have been more helpful in addressing your TA needs? (Open-ended text entry)

6. Please indicate the extent to which you agree or disagree with the following statements about performance measures.

HV-ImpACT’s technical assistance supported our performance on…	1 = Strongly agree; 2 = Agree; 3 = Somewhat agree; 4 = Somewhat disagree; 5 = Disagree; 6 = Strongly disagree; 7 = N/A
a. Staff recruitment and retention	1 2 3 4 5 6 7 (NA)
b. Place-based services	1 2 3 4 5 6 7 (NA)
c. Family engagement	1 2 3 4 5 6 7 (NA)
d. Program capacity	1 2 3 4 5 6 7 (NA)

7. Have you taken any action steps this past year as a result of HV-ImpACT’s technical assistance?

• Yes

• No

8. [If respondent chooses “yes” to Question #7] Please describe 1-2 action steps you have taken this year as a result of HV-ImpACT’s technical assistance. (Open-ended text entry)

9. [If respondent chooses “no” to Question #7] Please describe how HV-ImpACT’s technical assistance could have better supported you in taking action steps. (Open-ended text entry)

10. In what ways could we improve HV-ImpACT’s technical assistance to better support you? (Open-ended text entry)