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

Appendix B

OMB Control No. 0970-0401

Expiration Date: 05/31/2021

PATH Technical Assistance Evaluation Feedback Form

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 30 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 30 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.

Tribal Home Visiting Team Role
Please indicate if the Evaluation Feedback Form was completed as a group/team shared process or by one lead person.	☐ Individual ☐ Team
For those who participated in completing this form, please select the number of individuals in each home visiting role category.			Grantee Director/Manager/Coordinator
			Grantee Data/ Evaluation Staff
			Grantee Consultant
			Grantee Grants Management/Fiscal Staff
			Home Visitor
			Other (please specify) _________________________________________
How long have you been in this role? (skip logic if one “lead person” completed the form)	 Less than 1 year  3-5 years  1-3 years  More than 5 years
Provision of TA
In the last 12 months, did your program participate in any TA related to these topics (select all that apply)?	☐ Tribal/Organizational Leadership Support ☐ Quality Workforce & Quality Workforce Management ☐ Fidelity Monitoring/Model Fidelity ☐ Community & Partner Engagement ☐ Recruitment, Enrollment & Engagement of Families ☐ Dissemination ☐ Early Childhood Systems Building ☐ Policies and Procedures ☐ Sustainability ☐ Adaptation, Enhancements and Supplements ☐ Other (e.g., breastfeeding support for new mothers, depression, substance abuse) ­­­­­­­­­­ (please specify) ___
If you did not utilize TA, please explain why (e.g., your program did not have needs).
TA Outcomes
To what extent has your team improved their knowledge related to this topic due to PATH TA?	Tribal/Organizational Leadership Support
	Quality Workforce & Quality Workforce Management
	Fidelity Monitoring/Model Fidelity
	Community & Partner Engagement
	Recruitment, Enrollment & Engagement of Families
	Dissemination
	Early Childhood Systems Building
	Policies and Procedures
	Sustainability
	Adaptation, Enhancements and Supplements
	Other (please specify) ______________________
To what extent has your program implemented new strategies or made changes related to this topic due to PATH TA?	Tribal/Organizational Leadership Support
	Quality Workforce & Quality Workforce Management
	Fidelity Monitoring/Model Fidelity
	Community & Partner Engagement
	Recruitment, Enrollment & Engagement of Families
	Dissemination
	Early Childhood Systems Building
	Policies and Procedures
	Sustainability
	Adaptation, Enhancements and Supplements
	Other (please specify) _______________________
To what extent has PATH TA assisted you in achieving your implementation plan goals related to this topic?	Tribal/Organizational Leadership Support
	Quality Workforce & Quality Workforce Management
	Fidelity Monitoring/Model Fidelity
	Community & Partner Engagement
	Recruitment, Enrollment & Engagement of Families
	Dissemination
	Early Childhood Systems Building
	Policies and Procedures
	Sustainability
	Adaptation, Enhancements and Supplements
	Other (please specify) ______________________
Meeting TA Needs
How helpful are these TA method(s)?	Peer Calls	On-site or In-Person TA	PATH Resources & Tools	Individual TA by your TA Specialist Over the Phone or Video	Working Sessions (insert working session offered)		Virtual Site Visit TA	All Grantee Meeting (AGM) and Regional Meetings	Virtual Learning Opportunities (insert opportunities offered)
If you received TA in these topic areas, to what extent did PATH meet your TA needs?	Tribal/Organizational Leadership Support
	Quality Workforce
	Fidelity Monitoring/Model Fidelity
	Community & Partner Engagement
	Recruitment, Enrollment & Engagement of Families
	Dissemination
	Early Childhood Systems Building
	Policies and Procedures
	Sustainability
	Adaptation, Enhancement and Supplement
	Other­­­­­­­­­­ (please specify) _______________
What TA experiences with PATH would you say have been the most successful in helping your program meet the grant requirements? Why?
Briefly describe unmet TA needs.
Please provide additional information to help explain your responses.
Understanding of Tribes/Tribal Communities and Quality Relationships
PATH demonstrates a strong understanding of:
Tribal Home Visiting implementation.
how to effectively connect us with peers through various TA methods.
how to support us in achieving our home visiting program goals.
how to respect the unique positions of tribes.
the strength of our tribal community/organization.
how evidence-based home visiting models are best implemented in tribal communities.
the unique positions of home visiting within tribes and tribal communities.
Please provide additional information to help explain your responses.
My Path Specialist:
engages in inquiry to better understand our needs before engaging in TA.
is responsive to our unique needs.
is knowledgeable about our program.
engages in joint problem-solving.
demonstrates feelings of care and empathy.
has built a trusting and satisfactory relationship with our team.
is approachable, and we feel comfortable asking for support.
Overall, we are satisfied with our TA Specialist.
Is there more you would like to share about your TA Specialist?
Satisfaction with TA and Timeliness of TA
Overall, I am satisfied with PATH TA.
In the past 12 months, TA was delivered when it was relevant for your program.
How can PATH improve TA to better support your successful home visiting implementation?
Please provide additional information to help explain your responses.

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