C Attachment C-Community of Practice Survey

OMB No: 0915-0212

Expiration date: 07/31/2021

HV-ImpACT Community of Practice 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. Overall, how satisfied were you with this Community of Practice?

• Extremely satisfied

• Satisfied

• Somewhat satisfied

• Somewhat dissatisfied

• Dissatisfied

• Extremely dissatisfied

2. [If the respondent chooses “Somewhat dissatisfied.” “Dissatisfied,” or “Extremely dissatisfied”] Please explain why you were dissatisfied with the Community of Practice. (Open-ended text entry)

3. Please tell us the extent to which you agree or disagree with the following statements.

My participation in this Community of Practice…	1 = Strongly agree; 2 = Agree; 3 = Somewhat agree; 4 = Somewhat disagree; 5 = Disagree; 6 = Strongly disagree
a. Enhanced my organization’s ability to reach our performance measures	1 2 3 4 5 6
b. Provided an opportunity to interact with my peers.	1 2 3 4 5 6
c. Addressed a technical assistance need I have.	1 2 3 4 5 6
d. Connected me with useful resources.	1 2 3 4 5 6

4. [If the respondent chooses “Somewhat disagree,” “Disagree,” or “Strongly disagree”] How could the Community of Practice have better (insert display logic prompt(s) from Question #3)? (Open-ended text entry)

5. Have you taken any action steps as a result of your participation in the Community of Practice?

• Yes

• No

6. [If respondent chooses “Yes” in response to Question #5] Please describe 1-2 action steps you have taken this year as a result of your participation in the Community of Practice. (Open-ended text entry)

7. [If respondent chooses “No” in response to Question #5] Please describe how the Community of Practice could have better supported you in taking action steps. (Open-ended text entry)

8. Could you use additional support around [insert CoP specific topic]?

• Yes

• Maybe

• No

9. [If respondent chooses “Yes” or “Maybe” in response to Question #8] What kind of additional support would you like? (Open-ended text entry)

10. What aspects of the Community of Practice were most useful? (Open-ended text entry)

11. What can we do to improve future Communities of Practice? (Open-ended text entry)