Form 1 Annual Awardee Survey

OMB No: 0915-0212

Expiration date: 04/30/2024

Annual Awardee Survey

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 0915-0212. Public reporting burden for this collection of information is estimated to average 0.08 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.

Technical Assistance

1. Overall, how satisfied are you with the technical assistance (TA) you received from ITAC?

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 TA received: [Open text]

3. Have you taken any action steps as a result of the TA received?

   1. Yes

   2. No

4. [If yes] Please describe 1-2 action steps you have taken as a result of the TA received: [Open text]

5. [If no] Please describe how we could have better supported you in taking action steps: [Open text]

6. Please select the extent to which you agree with the following statements [Matrix]:

   1. My TA providers and I have a good relationship.

   2. My TA providers and I work together on setting goals for TA requests.

   3. My TA providers understand what I/my team is trying to accomplish with TA requests.

   4. My TA providers and I agree on what is important for me/my team to work on.

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

1. Strongly agree

2. Agree

3. Disagree

4. Strongly disagree

8. How satisfied are you with your TA planning process?

   1. Extremely satisfied

   2. Satisfied

   3. Dissatisfied

   4. Extremely dissatisfied

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

10. How satisfied are you with your monthly TA report summary from your TAS team?

    1. Extremely satisfied

    2. Satisfied

    3. Dissatisfied

    4. Extremely dissatisfied

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

12. How can we improve the quality of future TA services? [open text]

13. As we work to improve our technical assistance, would you be willing to speak with us if we wanted to follow up on some of the feedback that you provided (we would simply contact you via email)?

    1. Yes, I would be willing to speak with you

    2. No, I would prefer not to

Learning Collaborative

1. How satisfied are/were you with the Learning Collaborative (LC) sessions you attended this year? 

1. Extremely satisfied 

2. Satisfied 

3. Dissatisfied 

4. Extremely dissatisfied 

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

3. On a scale from 1-5, please rate how effective the LC is/was at connecting you with peers for collaboration. 

1. 1 (Not effective)  

2. 2 

3. 3  

4. 4 

5. 5 (Very effective) 

4. On a scale from 1-5, please rate how effective the LC is/was at helping you effectively implement your innovation.

1. 1 (Not effective)  

2. 2 

3. 3  

4. 4 

5. 5 (Very effective) 

5. On a scale from 1-5, please rate how effective the LC is/was at helping you effectively evaluate your innovation.

1. 1 (Not effective)  

2. 2 

3. 3  

4. 4 

5. 5 (Very effective) 

6. How can we improve future LCs? [Open text] 

4