Survivor Fellowship Fellow Feedback Form

NHTTAC Consultant and Evaluation Package

12- Survivor Fellowship Feedback

Survivor Fellowship Fellow Feedback Form

OMB: 0970-0519

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0970-0519 can be found here:

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OMB Control Number: 0970-0519
Expiration Date: 10/31/2021

SURVIVOR FELLOWSHIP
FEEDBACK
Form

In order to help the National Human Trafficking Training and Technical Assistance Center (NHTTAC) better serve the field, we
are reaching out to obtain your feedback. We will protect the privacy of your information in accordance with the Federal Privacy
Act, and we will protect the confidentiality of your responses using procedures we have in place, including reporting all
information in aggregate to avoid identifying information. Only members of the NHTTAC Evaluation Team have access to
information that could identify respondents. If you have any questions about this survey or the evaluation, please contact
NHTTACEval@icf.com.
Please provide the information below to create an anonymous ID:
______

______

Birth Month
(insert just the month
for your date of birth,
example: 08 for August)

First letter of first name
(example: S for Sara)

First letter of your middle name
(example: M for Maria)

Please rate the extent to which to you agree or disagree that the fellowship has helped your organization achieve the following
objectives.

FELLOWSHIP OBJECTIVES

Strongly
Disagree

Disagree

Agree

Strongly
Agree

Not
Applicable

The fellowship increased my leadership skills.

The fellowship increased my skills and knowledge
about survivor-informed practices.

The fellowship increased my skills and knowledge
about current evidence-based research and promising
practices.

The fellowship increased my skills and knowledge
about a multidisciplinary approach to addressing
human trafficking.

The fellowship increased my skills and knowledge
on a public health response to human trafficking.

The fellowship met my professional needs.

The fellowship met my educational needs.

I remained engaged with my partner organization in
the fellowship throughout its entirety.

[insert objective here].

10. [insert objective here].

11. Please list any other personal goals you have achieved through this fellowship program:

____________________________________________________________________________________
____________________________________________________________________________________

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid OMB control
number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the accuracy of this estimate or
additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or 9300 Lee Highway, Fairfax, VA 22031.

OMB Control Number: 0970-0519
Expiration Date: 10/31/2021

SURVIVOR FELLOWSHIP
FEEDBACK
Form

12. How were you invited to participate in this fellowship?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
13. Do you think NHTTAC should do anything differently when selecting people to participate in this fellowship?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Please indicate the extent to which you agree or disagree with the following statements about the Fellowship Activities:
Strongly
Disagree

Disagree

Agree

Strongly
Agree

18. [insert objective].

19. [insert objective].

20. I would recommend keeping the organizational audit as
part of future survivor fellowships organized by
NHTTAC.

Strongly
Disagree

Disagree

Agree

Strongly
Agree

21. The action plan was developed collaboratively between
me and the partner organization.

22. My partner organization and I had the appropriate tools
and resources to develop the action plan.

23. The action plan we developed defined clear roles and
responsibilities.

24. The action plan we developed accounted for the partner
organization’s culture and structure.

25. The action steps we created were grounded in a
multidisciplinary approach to addressing human
trafficking.

ORGANIZATIONAL AUDIT
14. The organization was cooperative during the
organizational audit.
15. I had the appropriate tools and resources to conduct the
organizational audit.
16. I had adequate time to collaborate with the organization
I was partnered with in this fellowship on the
organizational audit.
17. The organizational audit helped identify gaps in the
organization’s service provision to people who are
currently being trafficked, at risk of trafficking, or have
been trafficked

ACTION PLAN

OMB Control Number: 0970-0519
Expiration Date: 10/31/2021

SURVIVOR FELLOWSHIP
FEEDBACK
Form
26. The action steps we created were grounded in a public
health approach to addressing human trafficking.

27. The action plan accounts for complex and multiple
traumas.

28. The action plan we created accounts for all types of
trafficking.

29. The action plan we created includes action steps to
address language and cultural barriers to serving at-risk
populations or potential victims of human trafficking.

30. I recommend keeping the action plan development as
part of future survivor fellowships.

Strongly
Disagree

Disagree

Agree

Strongly
Agree

31. NHTTAC supported me with necessary information to
enhance the T/TA I provided to the organization.

32. The organization was receptive to the recommendations
and changes provided through the action plan.

33. I had the appropriate tools and resources to provide the
organization with customized T/TA.

34. I had adequate time to plan for the customized T/TA.

35. I had adequate time to provide the customized T/TA.

36. The structure of the fellowship was an appropriate way
to incorporate and engage survivors.

CUSTOMIZED T/TA

Please indicate the extent to which you agree or disagree with the following statements about your collaboration with
the fellow:

ORGANIZATION: _____________________

Strongly
Disagree

Disagree

Agree

Strongly
Agree

37. The organization was easy to communicate with
throughout fellowship activities.

38. The organization responded to me in a timely manner.

39. The organization was respectful.

40. The organization allotted an appropriate amount of time
for me to help make an actionable change at the
organization.

41. The organization responded in a helpful manner to my
questions.

OMB Control Number: 0970-0519
Expiration Date: 10/31/2021

SURVIVOR FELLOWSHIP
FEEDBACK
Form
Please indicate the extent to which you agree or disagree with the following statements:
Strongly
Disagree

Disagree

Agree

Strongly
Agree

Not Applicable

42. NHTTAC staff clearly articulated my responsibilities in this
fellowship.

43. NHTTAC set clear expectations for this fellowship.

NHTTAC STAFF: __________________

44. NHTTAC provided me with necessary resources and
materials for this fellowship program.
45. NHTTAC staff were detail-oriented and thorough in the
planning of this fellowship.
46. NHTTAC was responsive to my questions and needs.
47. NHTTAC provided me with additional information on a
public health approach to human trafficking upon request.
48. I am satisfied with the overall support provided by
NHTTAC staff throughout the fellowship program.

49. Is there anything additional NHTTAC could have done to support you during this fellowship?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
50. Please rate the overall quality of this fellowship program.
1

Poor

Fair

Good

Excellent

51. Overall, how well did this fellowship meet your expectations?
1

Far Below My
Expectations

Did Not Meet My
Expectations

Met My Expectations

Exceeded My
Expectations

52. How satisfied were you with the overall quality of the support you received from NHTTAC staff to help complete this
fellowship?
1

Very Dissatisfied

Dissatisfied

Satisfied

Very Satisfied

53. Would you recommend NHTTAC to others to receive T/TA?

□ Yes

□ No

OMB Control Number: 0970-0519
Expiration Date: 10/31/2021

SURVIVOR FELLOWSHIP
FEEDBACK
Form
54. What are three things you plan to do as a result of this fellowship?

__________________________________________________________________________________
__________________________________________________________________________________
55. Was the format of this fellowship conducive to improving best practices at the organization you partnered with during this
fellowship? Why or why not?

__________________________________________________________________________________
__________________________________________________________________________________
56. What aspects of the fellowship were most helpful and why?

__________________________________________________________________________________
__________________________________________________________________________________
57. What could NHTTAC do differently to improve similar fellowships in the future?

__________________________________________________________________________________
__________________________________________________________________________________
59. As a result of participating in this fellowship program, do you plan to do any of the following? (Mark all that apply.)

□
□
□
□
□
□
□
□
□
□

Change my management/leadership or
interpersonal communication style
Further develop skills and knowledge about serving
people who are currently being trafficked, at risk of
trafficking, or have been trafficked
Write grants/fundraise/identify new funding
resources
Advocate or meet with leadership of my
organization to develop/enhance vision, mission, or
strategic plan
Advocate or meet with leadership of my
organization to develop/enact policy changes at my
organization
Improve programs/practices
Improve technology/websites/infrastructure
Integrate victim-centered, survivor-informed
strategies
Expand services or types of services
Begin a new project or initiative

□
□
□
□
□
□

Develop/strengthen collaborative or strategic
relationships
Network with other participants
Share materials with colleagues
Provide information to clients/families/youth
Train/educate others in content/skills learned
Raise public awareness/advocacy/outreach
activities offered to people who are currently being
trafficked, at risk of trafficking, or have been
trafficked
Refer colleagues to NHTTAC events/resources
Conduct research
Strengthen evaluation or needs assessment
activities
Improve identification and reporting methods for
trafficking
Take additional training on human trafficking
Other (please specify): _____________________

OMB Control Number: 0970-0519
Expiration Date: 10/31/2021

SURVIVOR FELLOWSHIP
FEEDBACK
Form

60. Of the barriers listed below, which do you believe will be a significant challenge to performing the activities you selected
in the previous question? (Mark all that apply.)

□
□
□
□
□
□
□
□
□
61.

□
□
□
□
□
□
□
□
62.

□
□
□
□
□
□

Lack of senior leadership support
Lack of frontline support and accountability
Continuous turnover
Shortages of key personnel
Competing priorities
Inaccessible research and/or information
Lack of urgency
Lack of shared responsibility across
organizational collaboration
Difficulty in establishing and/or maintaining a
multi-disciplinary team

□

Need for partnership building with other
organizations
Variation in mission and regulatory
frameworks when partnering with other
organizations
Lack of information and/or data sharing among
organizations
Lack of time to implement changes
Lack of training for staff in how to implement
change
Other (please explain): ________________

□
□
□
□
□

Which of the following best describes your organization? (Mark all that apply.)
I do not represent an organization
Academic institution
Anti-trafficking organization
Business/For-profit organization
Coalition/Multidisciplinary team/Task force
Federal government
Faith-based organization
State and local government

□
□
□
□
□
□
□
□

Nonprofit/Community-based organization
OTIP grantee
Self-employed
Survivor-led organization
Tribal government
Union/Worker advocacy organization
Victim service provider
Other, please specify: _____________________

Which of the following best describes the types of services your organization provides? (Mark all that apply.)
Behavioral health professional (e.g.,
psychologist, psychiatrist, mental
health/substance use counselor)
Child welfare (e.g., state agency staff, child
welfare contractor, nonprofit personnel)
Corrections-based services (e.g., parole,
probation)
Criminal justice (e.g., law enforcement,
prosecutor, probation, court, forensic interviewer)
Educator (e.g., teacher, professor, school
administrator)
Health care (e.g., physician, physician assistant,
nurse practitioner, dentist, nurse, pharmacist)

□ Housing (e.g., case worker, shelter director, public
housing authority agencies)

□ Legal (e.g., immigration, civil and/or rights-based
attorney and/or paralegal, clinic)

□ Public health (e.g., licensure board, health department
□
□
□
□

staff, health care executive, community health
workers)
Social worker (e.g., case manager, school counselor,
supervisor, administrator)
Survivor empowerment, mentoring, or peer to peer
Violence prevention (e.g., Child abuse and neglect;
elder abuse; domestic violence, sexual violence, youth
violence)
Other (please specify):
_______________________________

63. Is your organization responsible for working with people who are currently being trafficked or have been trafficked?
□ Yes

□ No

OMB Control Number: 0970-0519
Expiration Date: 10/31/2021

SURVIVOR FELLOWSHIP
FEEDBACK
Form

64. Which of the following best describes your organization’s geographic population? (Mark all that apply.)
□
□
□
□

National
State (please specify): ______________
Tribal
International (please specify country):
_________________________________

□ Local
□ Urban
□ Rural
□ Suburban

65. Please select any of the following populations does your organization currently work with in a professional capacity
(Mark all that apply.)

□

□
□
□
□

□

Human trafficking
□ Commercial sexual exploitation of
children
□ Sex trafficking
□ Adults
□ Minors
□ Labor trafficking
□ Adults
□ Minors
Children/youth
□ Out of home/Foster care/Kinship care
□ Juvenile justice
□ Runaway/Homeless youth
People with disabilities
Deaf/Hearing impaired
Elderly
Lesbian, gay, bisexual, transgender, and
questioning

□
□

□
□
□
□
□

Foreign nationals (migrant workers,
undocumented immigrants, refugees)
People with low incomes
Racial and ethnic minorities
□ American Indian or Alaska Native
□ Asian
□ Black or African American
□ Native Hawaii or other Pacific
Islander
□ White
□ Hispanic or Latino ethnicity
History of substance use
Domestic and dating violence
Gang-related crime
Sexual abuse/Violence
Other (Please specify): __________________

66. In your professional capacity, how frequently does your organization come into contact with a person who is currently
being trafficked, at risk of being trafficked, or has been trafficked?
1

Never

Occasionally

Frequently

Daily

Thank you for taking the time to complete this form and helping to improve NHTTAC activities.

File Type	application/pdf
Author	Field, Michael
File Modified	2019-11-01
File Created	2019-11-01