Tribal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Technical Assistance Evaluation (TA) Survey and Immediate Feedback Tool

Appendix A

OMB Control No. 0970-0401

Expiration Date: 05/31/2021

PATH Technical Assistance Immediate Feedback Form

(administered after each TA occurrence)

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 0970-0401. Public reporting burden for this collection of information is estimated to an average of 6 minutes 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 Anne Bergan, Office of Child Care, Administration for Children and Families, HHS, Mary E. Switzer Building 330 C Street SW, Suite 3014F, Washington, DC 20024.

Use of Data: Thank you for providing feedback about the effectiveness of the TA you received. This form should take approximately 6 minutes to complete. Your feedback provides valuable information about the effectiveness of the TA provided by PATH. We analyze and review the results with rigor and incorporate your suggestions to continuously improve the quality of TA.

Please select the role that most closely aligns with your responsibilities related to the Tribal Home Visiting project.

Grantee Lead/Director/Coordinator Grantee Data/Evaluation Staff Grantee Program Staff/Consultant

Grantee Grants Management/Fiscal Staff Home Visitor

Please rate items 1-6

TA met my needs
This TA effectively met your needs.		This TA provided productive ways of learning.
This TA was engaging.		TA on this topic was delivered at a time when it was relevant for your program.
This TA met the intended goals/objectives.		TA offered options for next steps, ideas, or action items that can be applied soon.

TA facilitated new learning in the following areas:		I am planning on applying what I learned in the following areas:
Tribal/Organizational Leadership Support, Governance, and Administration		Tribal/Organizational Leadership Support, Governance, and Administration
Quality Workforce		Quality Workforce
Fidelity Monitoring / Model Fidelity		Fidelity Monitoring / Model Fidelity
Community and Partner Engagement		Community and Partner Engagement
Recruitment, Enrollment, and Engagement of Families		Recruitment, Enrollment, and Engagement of Families
Dissemination		Dissemination
Early Childhood Systems Building		Early Childhood Systems Building
Policies and Procedures		Policies and Procedures
Sustainability		Sustainability
Other topics (as applicable)		Other topics (as applicable)
(7) Other feedback