A Attachment A - HV-PMCQI Annual Survey

OMB No: 0915-0212

Expiration date: 07/31/2021

HV-PM/CQI TA Center Awardee Annual Survey

 

Public Burden Statement: 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 project is 0915-0212. Public reporting burden for this collection of information is estimated to average .18 hours 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 Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857.

HV-PMCQI is conducting a satisfaction survey to gather information about your experiences with the technical assistance received over the past 12 months. HV-PMCQI will not penalize or reward you based on your responses to this survey. It will take you approximately 11 minutes to complete the survey.

 

The information you provide will help us make improvements to future technical assistance activities. Your responses to the survey are strictly confidential. Your individual responses will not be reported.

 

Completing the survey is voluntary. If you have questions about this project, please contact Emma McAuley at emcauley@edc.org. We sincerely appreciate your time and willingness to participate.

 

By clicking "I agree" below you are indicating that you have read and understood this consent form and agree to participate in this survey. You may print a copy of this page for your records.

• I agree

• I do not agree [response takes user to end of survey]

1. HV-PMCQI has offered a range of technical assistance products and services in 2018, including webinars, written resources, and individualized assistance (one-on-one TA) with a TA Specialist.   

Have you accessed any HV-PMCQI technical assistance in the past 12 months? Check all that apply.

• Yes [response will show user HV-PMCQI block of questions]

• No [response takes user to end of survey]

• I don’t know [response takes user to end of survey]

2. Overall, how satisfied were you with the HV-PMCQI technical assistance you accessed this year?

• Extremely satisfied

• Satisfied

• Somewhat satisfied

• Somewhat dissatisfied

• Dissatisfied

• Extremely dissatisfied

3. [If user chooses options d-f in #2] Please explain why you were dissatisfied. Open-ended text response

4. How helpful was HV-PMCQI’s overall technical assistance in addressing your needs this year?

• Extremely helpful

• Very helpful

• Moderately helpful

• Slightly helpful

• Not at all helpful

5. [If user chooses options c-e in #4] Please explain how the technical assistance could have been more helpful. Open-ended text response

6. HV PMCQI’s technical assistance helped to improve your…

	1 = Strongly agree; 2 = Agree; 3 = Somewhat agree; 4 = Somewhat disagree; 5 = Disagree; 6 = Strongly disagree; 7 = N/A
a. Continuous Quality Improvement	1 2 3 4 5 6 7 (NA)
b. Data collection, analysis, and benchmarking activities	1 2 3 4 5 6 7 (NA)

7. Have you taken any action steps this past year as a result of HV-PMCQI’s technical assistance (i.e., informational requests, one-on-one technical assistance, and/or onsite technical assistance)?

• Yes

• No

8. [If user chooses “Yes” in #7] Please describe 1-2 action steps you have taken this year as a result of the technical assistance request. Open-ended text response

9. [If user chooses “No” in #7] Please describe how the technical assistance could have better supported you and your team move to action. Open-ended text response

10. [Displayed only for users who chose “Yes in #7] In what ways could HV-PMCQI improve the technical assistance to better support you? Open-ended text response

11. HV-PMCQI sent out four written resources this year addressing: [topics]. Have you accessed any of the below resource materials? Please check all that apply.

• Example

• Example

• Example

• I have not accessed these written resources (skip to final question block)

• I don’t know (skip to final question block)

Written Resource Question Block [displayed if user chooses any or all of the 4 examples listed in #11]

Overall, how satisfied were you with the following written resources?	1 = Extremely satisfied; 2 = Satisfied; 3 = Somewhat satisfied; 4 = Somewhat dissatisfied; 5 = Dissatisfied; 6 = Extremely dissatisfied
a. [Users are shown only the resources they stated they had accessed in #11]	1 2 3 4 5 6

1. How helpful were the resource materials in addressing your technical assistance needs?

• Extremely helpful

• Very helpful

• Moderately helpful

• Slightly helpful

• Not at all helpful

2. [Displayed if user chooses options c-e in #2] Please explain how the resource materials could have been more helpful. Open-ended text response

3. What aspects of the resource materials were most useful? Open-ended text response

4. What can we do to improve future resource materials? Open-ended text response

Final Question Block [shown to all users if they choose that they have accessed technical assistance from HV-PMCQI this past year]

1. What is your state/territory?

   1. Dropdown of all 56 awardees plus an N/A option