4 Attachment D_Webinar Survey

OMB No: 0915-0212

Expiration date: 04/30/2024

Webinar Survey

Disseminated at the end of each webinar

Public Burden Statement: The purpose of this information collection request is to assess participant satisfaction with various training and TA activities offered through a contracted TA provider, the Education Development Center. 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. This data collection is voluntary. The OMB control number for this project is 0915-0212 and is valid until 04/30/2024. 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. How satisfied were you with [title] webinar?

   1. Extremely satisfied

   2. Satisfied

   3. Dissatisfied

   4. Extremely dissatisfied

2. [If chosen “Dissatisfied” or “Extremely dissatisfied”] Please explain why you were dissatisfied with the webinar: [Open text]

3. What aspects of the webinar were most useful? [Open text]

4. What aspects of the webinar were least useful? [Open text]

5. Do you plan to apply what you learned today in your work?

   1. Yes

   2. No

6. [If yes] How do you plan to apply what you’ve learned today? Please select all that apply:

   1. I will send resources from this webinar to colleagues.

   2. I will review my CQI plan.

   3. I will share resources my team has developed around this topic with other awardees on the MALL.

   4. Other, please explain:

7. How can we improve future webinars? [Open text]

8. We are particularly interested in whether this webinar was provided in a culturally appropriate manner. Please rate your agreement with the following statement: This webinar was provided in a culturally responsive manner (respectful of individual beliefs, language, perspectives, and needs).

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree

9. [If disagree] Please explain how we could improve our TA in being more culturally responsive: [Open text]