2 Participant Follow-Up Form

OMB No. 0906-0104
Expiration Date: 11/30/2026

Participant Follow-Up
{Insert Activity}
Please take the necessary time to respond to each item on this evaluation form. Your candid and complete responses are
important so that we can better meet your learning needs.
1) As a result of your participation in {insert activity}, please select which actions you have taken in your job/work:
{insert action}
{insert action}
{insert action}
{insert action}
{insert action}
{insert action}
{insert action}
{insert action}
{insert action}
Not applicable. I have not applied the activity to my job.
Other (please briefly describe):

Select all that apply:

Remove unnecessary rows.

2) What else can you tell us about impact of the above actions on your organization? For example, has your organization:
Select all that apply:
{insert organizational impact}
{insert organizational impact}
{insert organizational impact}
{insert organizational impact}
{insert organizational impact}

Not applicable. My organization has not yet benefitted.
Other (please briefly describe):

Remove unnecessary rows.

3) What factors, if any, have hindered your ability to apply information or strategy from the {insert activity}?
Select all that apply:
{insert factor}
{insert factor}
{insert factor}
{insert factor}
Not applicable. There have been no barriers to applying information/strategy.
Other (please briefly describe):

Remove unnecessary rows.

4) What additional assistance, if any, would you like on the topic of {insert topic}?
5) Should there be questions about your feedback, may HRSA contact you to discuss further? Yes
If yes, please provide:
Name:
E-mail:
Telephone Number:

Thank you for taking the time to provide this feedback.

No

Public Burden Statement: The purpose of this collection is to assist with preparing for, and evaluating the reach and
effectiveness of, select meetings and workshops conducted by HRSA’s Office of Intergovernmental and External
Affairs. 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 information
collection is 0906-0104 and it is valid until 11/30/2027. This information collection is voluntary. Data will be private
to the extent permitted by the law. Public reporting burden for this collection of information is estimated to average
3.33 minutes 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 Information
Collection Clearance Officer, 5600 Fishers Lane, Room 14NWH04, Rockville, Maryland, 20857 or
[email protected]. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility
statement.