Instrument A MIECHV Site Visit Compliance Review Awardee Feedback Form Boilerplate

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Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program Site Visit Compliance Review 
Awardee Feedback Form
 
OMB Control No. 0915-0212
Expiration Date: 04/30/2024
Public Burden Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is [0915-0212]. This information collection is to support the Maternal, Infant, and Early Childhood (MIECHV) program for site visit compliance review. This information will be used to collect feedback for possible future improvements. The time required to complete this information collection is estimated to average less than [# minutes/hours] per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is voluntary and will be used for future program improvements]. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: HRSA Information Collection Clearance Officer, Room 14N39, 5600 Fishers Lane, Rockville, Maryland 20857 or [email protected], Attention: Information Collections Clearance Officer.
Introduction Letter

* 1. Dear Awardee,

Thank you for participating in the recent HRSA MIECHV Compliance Review site visit. To continuously improve our processes, we would like to get your feedback on the site visit and the staff assigned to the site visit. This survey will allow us to gather feedback and report any successes, recommendations for improvement, and/or challenges to HRSA immediately.

Your feedback helps us review our processes, assess our staff, and make any necessary improvements. Your responses are anonymous to HRSA, and the survey should take less than 15 minutes to complete. Please complete it within 5 business days of the date of receipt. If you have questions about the survey please contact the Project Manager, [name, email, phone number].  We look forward to your feedback.

Pre-Site Visit

This section is an evaluation of the pre-site visit activities that occurred in preparation for your site visit. When answering these questions please think specifically about the planning phase of the site visit.
* 2. Did you participate in a pre-site visit conference call?
   Yes    No

    • 3. The planning for the site visit was timely and responsive to our needs.
Disagree Strongly	Disagree	Undecided	Agree	Strongly Agree	N/A

    • 4. The pre-site visit planning calls helped us prepare for the site visit.
Disagree Strongly	Disagree	Undecided	Agree	Strongly Agree	N/A

    • 5.  The Site Visit Readiness Checklist helped us prepare for the site visit.
Disagree Strongly	Disagree	Undecided	Agree	Strongly Agree	N/A

    • 6.  The Site Visit Assessment Tool helped us prepare for the site visit.
Disagree Strongly	Disagree	Undecided	Agree	Strongly Agree	N/A

    • 7. Expectations of the site visit were clearly articulated.
Disagree Strongly	Disagree	Undecided	Agree	Strongly Agree	N/A

    • 8. Please provide any additional comments/ recommendations about the pre-site visit process.


Site Visit – Programmatic Consultant

This section is an evaluation of the programmatic consultant assigned to your site visit. When answering these questions please think specifically about that member of the site visit team.
    • 9. Site Visit Staff: 
    • Who is the Programmatic Consultant that visited you?        

The Programmatic Consultant…
    • 10. Exhibited appropriate knowledge of MIECHV programs.
Disagree Strongly	Disagree	Undecided	Agree	Strongly Agree	N/A

    • 11. Was well prepared, demonstrated knowledge of our organization, the Site Visit Assessment Tool and the HRSA site visit process.
Disagree Strongly	Disagree	Undecided	Agree	Strongly Agree	N/A

    • 12. Was objective and professional
Disagree Strongly	Disagree	Undecided	Agree	Strongly Agree	N/A


    • 13. Effectively utilized the Site Visit Assessment Tool and the probing questions to frame the discussion and to add clarity to the items being assessed.
Disagree Strongly	Disagree	Undecided	Agree	Strongly Agree	N/A



     14. Please provide any additional comments concerning the programmatic consultant.













Site Visit - Fiscal Consultant


This section is an evaluation of the fiscal consultant assigned to your site visit. When answering these questions please think specifically about that member of the site visit team.
    • 15. Site Visit Staff:
    •  Who is the Fiscal Consultant that visited you?        

The Fiscal Consultant…

    • 16. Exhibited appropriate knowledge of MIECHV programs
Disagree Strongly	Disagree	Undecided	Agree	Strongly Agree	N/A

    • 17. Was well prepared, demonstrated knowledge of our organization, the Site Visit Assessment Tool and the HRSA site visit process.
Disagree Strongly	Disagree	Undecided	Agree	Strongly Agree	N/A

    • 18. Was objective and professional.
Disagree Strongly	Disagree	Undecided	Agree	Strongly Agree	N/A


    • 19. Effectively utilized the Site Visit Assessment Tool and the probing questions to frame the discussion and to add clarity to the items being assessed.
Disagree Strongly	Disagree	Undecided	Agree	Strongly Agree	N/A



    • 20. Please provide any additional comments concerning the fiscal consultant. 











This section is an evaluation of the notetaker assigned to your site visit. When answering these questions please think specifically about that member of the site visit team.

    • 21. The notetaker demonstrated professionalism in supporting the site visit. 
Disagree Strongly	Disagree	Undecided	Agree	Strongly Agree	N/A

    • 22. Please provide any additional comments concerning the notetaker.




    • 23. The site visit debriefing provided an accurate account of the discussions during the site visit.
Disagree Strongly	Disagree	Undecided	Agree	Strongly Agree	N/A


    • 24. What were the most significant challenges you encountered during the site visit? Check all that apply.
        ◦ Document Requests
        ◦ Technology (Please describe: ______________)
        ◦ Staff or Partners Not Available
        ◦ Limited Time for Discussions with Consultants and HRSA Staff
        ◦ Meeting Days Too Long
        ◦ Meeting Days Too Short
        ◦ Virtual Visit / Challenges of Virtual Participation
        ◦ Other (Please describe: ______________)
        ◦ No Challenges





 
    • 25. What worked well during the site visit? 



    • 26. Please provide any additional comments about the site visit process.







Thank you for completing this survey! If you have additional comments or questions about this survey please contact the Project Manager, [name, email, phone number].