OMB No: 0906-0040
Expiration Date: XX/XX/XXXX
Sample F2F HIC Survey Data Log
S = screener questions included at the beginning of each survey.
Q = corresponds to the feedback survey question.
Excel Tab 1: Families
Respondent Identifier |
Response Type |
Response date |
S1 |
S1.1 |
S2 |
S3 |
S4 |
S5 |
S6 |
S6.1 |
S7 |
Q1 |
Q2 |
Q3 |
Q4 |
*Average Feedback Score |
SMI245 |
Family |
2/3/23 |
1 |
CP |
1 |
0 |
0 |
0 |
0 |
N/A |
0 |
4 |
4 |
4 |
1 |
3.25 |
MUR010 |
Family |
2/7/23 |
0 |
N/A |
1 |
0 |
0 |
1 |
1 |
N/A |
0 |
4 |
3 |
3 |
4 |
3.5 |
Totals |
|
|
1 |
|
2 |
0 |
0 |
1 |
1 |
|
0 |
8 |
7 |
7 |
5 |
|
Excel Tab 2: Professionals
Respondent Identifier |
Response Type |
Response date |
S1 |
S2 |
S3 |
S4 |
S5 |
S6 |
S6.1 |
S7 |
Q1 |
Q2 |
Q3 |
Q4 |
*Average Feedback Score |
DIA007 |
Professional |
2/6/23 |
0 |
1 |
0 |
1 |
0 |
1 |
IEP |
0 |
3 |
3 |
3 |
2 |
2.75 |
KRA874 |
Professional |
2/10/23 |
1 |
1 |
1 |
1 |
1 |
0 |
N/A |
0 |
4 |
4 |
4 |
4 |
4 |
Totals |
|
|
1 |
2 |
1 |
2 |
1 |
1 |
|
0 |
7 |
7 |
7 |
6 |
|
Excel Tab 3: Training Participants
Respondent Identifier |
Response Type |
Response date |
S1 |
S2 |
Q1 |
Q2 |
Q3 |
Q4 |
*Average Feedback Score |
ABC321 |
Trainee |
2/10/23 |
0 |
1 |
2 |
1 |
4 |
3 |
2.5 |
LPS041 |
Trainee |
2/10/23 |
1 |
0 |
N/A |
N/A |
N/A |
N/A |
|
Totals |
|
|
1 |
1 |
2 |
1 |
4 |
3 |
|
* The average feedback score for each survey = total score from all feedback survey questions (Q) / four (4) questions.
HRSA may choose to report on a specific question. For example, 90% of families who responded to the F2F HIC feedback survey reported they would recommend the F2F to other families or professionals.
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 0906-0040. Public reporting burden for this collection of information is estimated to average .15 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.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Zerislassie, Tigisty (HRSA) |
| File Modified | 0000-00-00 |
| File Created | 2022-01-19 |