0920-21BL Technical Assistance Feedback Form

Evaluation of the Overdose Data to Action Technical Assistance Hub

Att 3. TA Feedback Form

OMB: 0920-1355

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Division of Overdose Prevention Technical Assistance Hub







OMB #0920-new



Attachment 3. Technical Assistance Feedback Form





































Form Approved

OMB No. 0920-XXXX

Exp. Date: XX-XX-XXXX



Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)



Technical assistance (TA) Feedback Form


Introduction

ICF, under contract with the Center for Disease Control (CDC), manages and evaluates the Overdose Data to Action (OD2A) technical assistance (TA).This survey is to gather your feedback regarding the perceived quality and effectiveness of the TA offered through the CDC DOP TA Center. Our goal is to provide the best assistance to support your work and this feedback will help us to make that TA better. The survey is designed to take about 5 minutes to complete.



Informed Consent

  • Your participation is voluntary. You may refuse to answer any questions or stop the survey at any time.

  • ICF will have access to your contact information when you complete this survey. However, ICF will aggregate and de-identify responses when reporting to CDC. ICF will not link your name with your individual responses in any reports to CDC. ICF will maintain your responses in a secure manner.

  • There are no right or wrong answers or ideas—we want to hear your experiences and opinions.

  • There are no risks to you or your organization for participating in this survey. The information will be used to improve the training and TA provided to OD2A recipients.

  • If you have questions about the survey or Institutional Review Board (IRB) approval, contact Megan Brooks at [email protected].



I confirm that I have read the information above and agree to participate in the survey.



Agree, continue to the survey





Survey



Please indicate the OD2A recipient organization you are affiliated with:

Create drop down list of organizations



Alabama Department of Public Health

Georgia Department of Public Health

North Carolina Department of Health and Human Services

Alaska Department of Health & Social Services

Hamilton County General Health District (OH)

Ohio Department of Health

Allegheny County Health Department (PA)

Harris County (TX)

Oklahoma State Department of Health

Arizona Department of Health Services

Hawaii State Department of Health-Behavioral Health Administration

Oregon Health Authority, Public Health Division

Arkansas Department of Health

Health Research, Inc. (New York State Department of Health)

Pennsylvania Department of Health

Baltimore County Government (MD)

Idaho Department of Health and Welfare

Philadelphia Department of Public Health (PA)

California Department of Public Health

Illinois Department of Public Health

Puerto Rico Department of Health

City of Chicago, Department of Public Health

Indiana State Department of Health

Rhode Island Department of Health

Colorado Dept of Public Health & Environment

Iowa Department of Public Health

South Carolina Department of Health and Environmental Control

Commonwealth Healthcare Corporation (Northern Marianna Islands)

Kansas Department of Health and Environment

South Dakota Department of Health

Commonwealth of Massachusetts

Louisiana Office of Public Health

Southern Nevada Health District (Clark County, NV )

Connecticut Department of Public Health

Maine Department of Health and Human Services

Tennessee Department of Health

County of Riverside Department of Public Health (CA)

Maricopa County (AZ)

Thomes E Dobbs (Mississippi State Department of Health)

County of San Diego Health and Human Services Agency

Maryland Department of Health

University of Kentucky Research Foundation

Cuyahoga County Board of Health (OH)

Michigan Department of Health and Human Services

Utah Department of Health

Delaware Department of Health and Social Services

Minnesota Department of Health

Vermont State Agency of Human Services

District of Columbia Department of Health

Missouri Department of Health and Senior Services

Virginia Department of Health

Florida Department of Health

Montana Department of Public Health and Human Services

Washington State Department of Health

Florida Department of Health in Broward County (FL)

Nebraska Dept of Health and Human Services

West Virginia Department of Health and Human Resources

Florida Department of Health in Duval County

Nevada Department of Health and Human Services

Wisconsin Department of Health Services

Florida Department of Health, Palm Beach County (FL)

New Hampshire Department of Health and Human Services

 

Franklin County Board of Commissioners/Public Health (OH)

New Jersey Department of Health

 

Fund for Public Health in New York, Inc. (NYC Health)

New Mexico Department of Health

 



Which of the following best describes your role on the OD2A team?

(Please choose only one – drop down list)

Create drop down list of key roles

[For direct TA activities only] Who was the provider of the technical assistance activity listed in your invitation email?

(Please choose only one – drop down list)

Create drop down list of TA providers

This survey is referring to the specific TA activity listed in your invitation email. Please select the response that best represents your rating for this TA activity for each of the following questions.




Poor

Fair

Good

Very Good

Excellent

Please rate the overall quality of this activity.







Strongly Disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly Agree

My knowledge and/or skills increased as a result of this activity.






The information and materials shared were useful to my work.






The length and pace of the activity was appropriate.






The materials and information were appropriate for my level of experience and knowledge.






The knowledge and expertise of this trainer/presenter were appropriate for this activity.






Additional Items for Webinars

The webinar met the following objectives:

<insert specific webinar objectives>






The webinar technology provided a positive learning environment.






The event connected us with the appropriate peers/agencies.






Additional Items for Peer-to-Peer Exchange Sessions

The event connected us with the appropriate peers/agencies.






The event gave access to subject matter experts.






Additional Item for In-Person Training/Site Visit

The training met the stated objectives:

<insert specific training objectives>






Additional items for ALL group TA Events

Participation and interaction were encouraged.






The overall quality of the event met my expectations.












OPEN ENDED QUESTIONS

How do you plan to apply the information from this activity to your work?



What was MOST valuable about the activity in which you participated?



What was LEAST valuable about the activity in which you participated?



What suggestions do you have for improving training and technical assistance activities?



What additional technical assistance needs do you or your organization have?
























































Thank you for your participation!



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