Appendix 1_Survey Questions_Site Visit Evaluation_ Six m

Appendix 1

Form Approved

OMB No. 0920-1027

Expiration Date 08/31/2017

TB Laboratory Site Visit Evaluation: Six-month Follow-up

Welcome!

This data collection is meant for state and local public health laboratory supervisors, or their designees, who administer tuberculosis laboratory services and are funded by Division of Tuberculosis Elimination (DTBE) cooperative agreements. Approximately six months ago, a Laboratory Capacity Team (LCT) Consultant from the Centers for Disease Control and Prevention, Division of Tuberculosis Elimination, Laboratory Branch, conducted a site visit at your TB laboratory. LCT would like to learn how your laboratory has used the recommendations provided in the site visit report to enhance areas of safety, testing algorithms, turnaround time indicators, and collaboration with partners.

Your feedback is very important and the information you provide will be valuable for evaluating program activities.

Completion of the assessment is voluntary and will take approximately 15 minutes. All information will be kept secure and will not be linked to any individual. Upon submission, you will immediately receive an email confirmation with a copy of your completed survey for your records. To begin, please click the NEXT button.

CDC estimates the average public reporting burden for this collection of information as 15 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1027).

1. The laboratory site visit report and recommendations were reviewed.

☐ Agree

☐ Disagree

☐ Indifferent/No response

2. The laboratory site visit report and recommendations were shared with other personnel including:

(Check all that apply)

☐ Microbiology supervisor

☐ Laboratory director/assistant laboratory director

☐ TB Control Program

☐ No one

☐ Other (please specify): ___________________

3. Recommendations provided in the site visit report were helpful.

☐ Agree

☐ Disagree

☐ Indifferent/No response

4. Based on recommendations included in the site visit report :

Please describe examples of changes that were made in laboratory practice:

Were there recommendations you chose not to address? Please describe:

Please describe any barriers that either interfered with or prevented implementing changes in laboratory practice:

5. It is expected that changes may allow the TB laboratory to:

(Check all that apply)

☐ Reduce expenditures

☐ Increase workflow efficiency

☐ Eliminate/reduce redundant testing

☐ Increase collaboration with partners (TB Control Program, other laboratory staff, etc.)

☐ Other (please specify): ____________________________

6. In the future, it would be reasonable for our laboratory to submit written responses regarding site visit recommendations to the Laboratory Capacity Team.

☐ Agree

☐ Disagree

☐ Indifferent/No response

7. Please provide any additional comments: