Form 1 Attachment A_Individualized Targeted TA Check in

OMB No: 0915-0212

Expiration date: 04/30/2024

Individualized (Targeted) TA Check-in

Sent once partway into a TA request as a check-in

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 are you with the targeted technical assistance you have received thus far from TARC?

   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 request: [Open text]

3. Below are the objectives created during the TA request by you and your TA Specialist(s). Please indicate the extent to which you agree that these objectives still represent your goals for the TA: [Matrix]

   1. Objective

   2. Objective

4. How satisfied with how frequently you and your TA Specialist(s) communicate regarding this request?

   1. Extremely satisfied

   2. Satisfied

   3. Dissatisfied

   4. Extremely dissatisfied

5. [If Dissatisfied/Extremely dissatisfied] Please explain why you are dissatisfied with the communication with your TA Specialist(s): [Open text]

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

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. How could we better support you in this TA request?

8. 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