Form 7 Post-Technical Assistance Evaluation Form

Attachment H - Post-Technical Assistance Evaluation Form

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Post- Technical Assistance Evaluation Form

Please take a minute to complete the following survey; it should take no more than 2 minutes to complete. It will help us evaluate the Learning Collaboratives.

This top section to be completed by project team
Tool Name: Date of Training: Type of Practice (Inpatient/hospital, Rural/CAH, Urban, Ambulatory Care, FQHC, etc.) Number of attendees: Primary Professional Role for each attendee
Immediate Post-TA (Learning Collaborative) Evaluation Survey Questions
	Strongly Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Strongly Agree
This Learning Collaborative meeting improved my understanding of how to use [TOOL NAME] to improve diagnostic safety in my practice/HCO.
This Learning Collaborative meeting improved my confidence to use [TOOL NAME] to improve diagnostic safety in my practice/HCO.
I plan to attend future Learning Collaborative meeting(s).

This survey is authorized under 42 U.S.C. 299a. This information collection is voluntary and the confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 2 minutes per response, the estimated time required to complete the survey. 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 data you provide will help AHRQ’s mission to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-xxxx) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857, or by email to the AHRQ MEPS Project Director at [email protected].

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