OMB No: 0915-0212
Expiration date: 07/31/2021
HV-ImpACT Event 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.
What is your project role?
MIECHV awardee
Other, please explain:__________
What is your state/territory
Dropdown response with all 56 state/territory options and “N/A”
Overall, how satisfied were you with the (insert HV-ImpACT event)?
Extremely satisfied
Satisfied
Somewhat satisfied
Somewhat dissatisfied
Dissatisfied
Extremely dissatisfied
[If respondent chooses “Somewhat dissatisfied,” “Dissatisfied,” or “Extremely dissatisfied”] Please explain why you were dissatisfied with the (HV-ImpACT event). (Open-ended text entry)
Please tell us the extent to which you agree or disagree with the following statements.
This (HV-ImpACT event)…
|
1 = Strongly agree; 2 = Agree; 3 = Somewhat agree; 4 = Somewhat disagree; 5 = Disagree; 6 = Strongly disagree; 7 = N/A |
a. Enhanced my organization’s ability to reach our performances |
1 2 3 4 5 6 |
b. Addressed a (technical assistance need I have/question I had about this model). |
1 2 3 4 5 6 |
c. Connected me with useful resources. |
1 2 3 4 5 6 |
d. [For HV-ImpACT events with interaction] Provided an opportunity to interact with my peers. |
1 2 3 4 5 6 |
[If respondent chooses “Somewhat disagree,” “Disagree,” or “Strongly disagree”] Please explain how the (HV-ImpACT event) could have better supported you. (Open-ended text entry)
What aspects of the (HV-ImpACT event) were most useful? (Open-ended text entry)
What can we do to improve future (HV-ImpACT event)? (Open-ended text entry)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | McAuley, Emma |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |