Form 0920-1355 TA Feedback Form – Individual TA

TA Feedback Form – Individual TA

Form Approved

OMB No. 0920-1355

Exp. Date: 11/30/2024

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-1355)

Description and Administration 

This survey goes to all TA recipients who receive individual TA immediately after completing the request. The DOP TAC website triaging system automatically sends this survey link once the TA provider confirms the completion of the request.  

Questions

Please indicate the DOP TAC state-recipient organization you are affiliated with: [drop-down list of all the state jurisdictions]

Please indicate the DOP TAC local-recipient organization you are affiliated with: [drop-down list of all the local jurisdictions]

Which of the following best describes your role on the DOP TAC team?

• Project manager

• Prevention staff

• Surveillance staff

• Evaluator

• Other (please specify)

1. How satisfied are you with the technical assistance provided?

• Very dissatisfied

• Dissatisfied

• Neither

• Satisfied

• Very satisfied

2. The TA provider was knowledgeable in the subject area:

• Strongly disagree

• Disagree

• Neither

• Agree

• Strongly agree

3. The technical assistance increased my knowledge and/or skill about the topic (s) addressed:

• Strongly disagree

• Disagree

• Neither

• Agree

• Strongly agree

4. Did the TA session address the issues for which you sought TA? 

• No

• Partially

• Yes

5. If you answered ‘No’ or ‘Partially’ in the previous question, please describe any additional technical assistance needed.

6. How do you plan to apply the information from the session to your work?