Form Training Feedback Training Feedback Training Feedback Form

Attachment B: Training Feedback Form

OMB No. 0930-0xxx

Expiration Date:  xx/xx/xx

 

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 0930-0xxx.  Public reporting burden for this collection of information is estimated to average 60 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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 SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

INITIAL EMAIL

Dear <first name> <last name>,

Our records indicate that you just participated in the following event delivered/supported by the Center of Excellence for the Infant and Early Childhood Mental Health Consultation (IECMHC) initiative:

<event name>

<event date>

As the Center of Excellence evaluators, we are interested in learning about your experiences so we can improve our trainings and technical assistance. Accordingly, we ask that you complete this brief feedback form. Please note, however, that your participation in completing the form is voluntary. The process is very simple. We ask that you take just a few minutes to complete a brief online survey to provide your thoughts. Options are described below.

To complete the survey, click the link below, choose "YES" on the first page, and follow the instructions:

<link to survey>

If you do not wish to participate, follow the same link above and you will see an option to remove you from the process. (Choose "NO" on the first page and follow the instructions.) Following the link and opting out will ensure that you will not be contacted about this again. As we are required to contact all participants, we will follow up if we haven't heard back from you within one week.

If you have any technical difficulties or questions about this process, or if you did not attend the event and have received this message in error, please contact the evaluation representative, <name of evaluation representative>, at <phone number of evaluation representative> or <email of evaluation representative>.

We value your input and thank you in advance for your time,

The Center of Excellence Evaluation Staff

TRAINING FEEDBACK FORM

Thank you for agreeing to provide us with feedback on the recent event described in the feedback invitation. We ask that you limit your responses only to that particular event.

1. Overall, how satisfied are you with this session
   <Very Satisfied, Somewhat Satisfied, Somewhat Dissatisfied, Very Dissatisfied, No Response>

2. How likely are you to use the information or ideas received in this session?
   <Very Likely, Somewhat Likely, Not Very Likely, Not At All Likely, No Response>

3. How much more knowledgeable are you about the session content after participating?
   <Much More Knowledgeable, Fairly More Knowledgeable, Somewhat More Knowledgeable, A Little More Knowledgeable, No More Knowledgeable, No Response>

4. How prepared are you now, after participating in this session, to do each of the following? (Choose one for each item, and include any comments you may have.)
   <List of content objectives, tailored to the training content provided>

<Very Prepared, Mostly Prepared, Somewhat Prepared, Not Very Prepared, Not At All Prepared, No Response><box for open-ended responses>

If respondent answers Very Prepared, Mostly Prepared or Somewhat Prepared, skip to Question 6.

5. What would help you feel more prepared?

<box for open-ended responses>

6. Please rate your agreement with the following statement:
   This service was provided in a culturally appropriate manner (respectful of individual beliefs, language, perspectives, and needs).
   <Strongly Agree, Agree, Neutral, Disagree, Strongly Disagree, No Response>

7. Can you identify any way(s) in which this service could more effectively respond to your beliefs, language, perspectives, and/or needs, or those of others?
   <box for open-ended responses>

We are required to collect demographic information on recipients of this service. Your responses will remain private and will only be reported in aggregate with those of other participants.

8. Which of the following best describes you in terms of Hispanic or Latino heritage? (Choose one.)

• Hispanic/Latino

• Not Hispanic/Latino

• I prefer not to answer

9. Which of the following best describes you in terms of race/ethnicity? (Choose all that apply.)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Pacific Islander

• White

• I prefer not to answer

Thank you for your feedback. Click on the button below to submit your response.

FINAL EMAIL

Dear <first name> <last name>,

Our records indicate that you just participated in the following event delivered/supported by the Center of Excellence for the Infant and Early Childhood Mental Health Consultation (IECMHC) initiative:

<event name>

<event date>

As the Center of Excellence evaluators, we are required to contact you and ask that you complete this brief feedback form. Please note, however, that your participation in completing the form is voluntary. The process is very simple. We ask that you take just a few minutes to complete a brief online survey to provide your thoughts. Options are described below.

To complete the survey, click the link below, choose "YES" on the first page, and follow the instructions:

<link to survey>

If you do not wish to participate, follow the same link above and you will see an option to remove you from the process. (Choose "NO" on the first page and follow the instructions.) Following the link and opting out will ensure that you will not be contacted about this again.

We will be closing access to this feedback form very soon. Can you please reply by <survey closing date>?

If you have any technical difficulties or questions about this process, or if you did not attend the event and have received this message in error, please contact the evaluation representative, <name of evaluation representative>, at <phone number of evaluation representative> or <email of evaluation representative>.

We value your input and thank you in advance for your time,

The Center of Excellence Evaluation Staff