Form 0920-1355 Implementation Feedback Form

Implementation Feedback Form

Form Approved

OMB No. 0920-1355

Exp. Date: 11/30/2024

Public reporting burden of this collection of information is estimated to average 15 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 longer-term follow-up survey goes to participants from group events to collect information on how they have applied the knowledge gained to their work three months after the session. This survey will be administered to participants who attended sessions with a clear intent to impart knowledge and build skills that can feasibly be applied to daily work efforts. The TA team will highlight these sessions (universal or focused events) in the survey tracking log, and the evaluation team will share the follow-up survey link with the TA team for administration a week before the three-month mark. Follow-up surveys for the individual events will be automatically sent to recipients three months after 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. As a result of this event [event name], I/our organization has applied knowledge and/or skills about the topic(s) learned to my/our work/programming:

• Strongly disagree

• Disagree

• Neither

• Agree

• Strongly agree

2. Please provide examples of how the knowledge and/or skills have been applied to your work or how it has impacted your organization

3. Please describe any challenges you have encountered in implementing what you learned

4. Describe how you overcome these challenges and what support, if any, you need to address them effectively