Document
FTCA Site Visit Follow-Up Survey
ICR 202608-0906-005 · OMB 0906-0084 · Object 171762200.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | FTCA Site Visit Follow-Up Survey |
| Author | Watson-Haye, Denise (HRSA) |
| Last Modified By | Writer |
| File Modified | 2026-08-13 |
| File Created | 2026-08-28 |
| Conversion State | complete |
Extracted Text
Thank you for participating in the FTCA site visit. Please read each statement carefully and select the response that best reflects your level of agreement. Your responses will be kept confidential and will be used only to help improve future site visits provided to health centers. Questions: 1. Job Title: Please select the option that best describes your role. (Required) ☐ Management Staff ☐ Governing Board Member ☐ Clinical Staff ☐ Non-Clinical Staff ☐ Risk Manager ☐ Quality Improvement / Quality Assurance (QI/QA) Manager ☐ Other (please specify): __________ 2. The FTCA pre-site visit call, training materials, and instructions adequately prepared me for the site visit. (Required) ☐ Strongly Agree ☐ Agree ☐ Neither Agree nor Disagree ☐ Disagree ☐ Strongly Disagree 3. The site visit agenda and expectations were clearly communicated prior to the visit. (Required) ☐ Strongly Agree ☐ Agree ☐ Neither Agree nor Disagree ☐ Disagree ☐ Strongly Disagree 4. The site visit meetings followed the approved agenda and schedule. (Required) ☐ Strongly Agree ☐ Agree ☐ Neither Agree nor Disagree ☐ Disagree ☐ Strongly Disagree 5. The FTCA site visit team provided helpful oversight during the review process (e.g., participated in interviews, reviewed documents, and responded to staff questions). (Required) ☐ Strongly Agree ☐ Agree ☐ Neither Agree nor Disagree ☐ Disagree ☐ Strongly Disagree 6. The FTCA site visit increased my knowledge of how to maintain FTCA program compliance. (Required) ☐ Strongly Agree ☐ Agree ☐ Neither Agree nor Disagree ☐ Disagree ☐ Strongly Disagree 7. Overall, I was satisfied with the FTCA site visit experience. (Required) ☐ Strongly Agree ☐ Agree ☐ Neither Agree nor Disagree ☐ Disagree ☐ Strongly Disagree 8. Additional comments or suggestions to improve future FTCA site visits: (Optional) Public Burden Statement: The purpose of the Federal Tort Claims Act (FTCA) Site Visit Follow-Up Survey is to obtain feedback from FTCA site visit participants on the effectiveness of the visit and to help identify challenges and areas in need of improvement. This information is used to support program and customer service improvements. 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 0906-0084 and it is valid until XX/XX/XXXX. 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 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 13N82, Rockville, Maryland, 20857 or [email protected]. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.