0920-21BL Technical Assistance Feedback Form

Division of Overdose Prevention Technical Assistance Hub

OMB #0920-new

Attachment 3. Technical Assistance Feedback Form

Form Approved

OMB No. 0920-XXXX

Exp. Date: XX-XX-XXXX

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

Technical assistance (TA) Feedback Form

Introduction

ICF, under contract with the Center for Disease Control (CDC), manages and evaluates the Overdose Data to Action (OD2A) technical assistance (TA).This survey is to gather your feedback regarding the perceived quality and effectiveness of the TA offered through the CDC DOP TA Center. Our goal is to provide the best assistance to support your work and this feedback will help us to make that TA better. The survey is designed to take about 5 minutes to complete.

Informed Consent

• Your participation is voluntary. You may refuse to answer any questions or stop the survey at any time.

• ICF will have access to your contact information when you complete this survey. However, ICF will aggregate and de-identify responses when reporting to CDC. ICF will not link your name with your individual responses in any reports to CDC. ICF will maintain your responses in a secure manner.

• There are no right or wrong answers or ideas—we want to hear your experiences and opinions.

• There are no risks to you or your organization for participating in this survey. The information will be used to improve the training and TA provided to OD2A recipients.

• If you have questions about the survey or Institutional Review Board (IRB) approval, contact Megan Brooks at megan.brooks@icf.com.

I confirm that I have read the information above and agree to participate in the survey.

☐ Agree, continue to the survey

Survey

Please indicate the OD2A recipient organization you are affiliated with:

Create drop down list of organizations

Alabama Department of Public Health	Georgia Department of Public Health	North Carolina Department of Health and Human Services
Alaska Department of Health & Social Services	Hamilton County General Health District (OH)	Ohio Department of Health
Allegheny County Health Department (PA)	Harris County (TX)	Oklahoma State Department of Health
Arizona Department of Health Services	Hawaii State Department of Health-Behavioral Health Administration	Oregon Health Authority, Public Health Division
Arkansas Department of Health	Health Research, Inc. (New York State Department of Health)	Pennsylvania Department of Health
Baltimore County Government (MD)	Idaho Department of Health and Welfare	Philadelphia Department of Public Health (PA)
California Department of Public Health	Illinois Department of Public Health	Puerto Rico Department of Health
City of Chicago, Department of Public Health	Indiana State Department of Health	Rhode Island Department of Health
Colorado Dept of Public Health & Environment	Iowa Department of Public Health	South Carolina Department of Health and Environmental Control
Commonwealth Healthcare Corporation (Northern Marianna Islands)	Kansas Department of Health and Environment	South Dakota Department of Health
Commonwealth of Massachusetts	Louisiana Office of Public Health	Southern Nevada Health District (Clark County, NV )
Connecticut Department of Public Health	Maine Department of Health and Human Services	Tennessee Department of Health
County of Riverside Department of Public Health (CA)	Maricopa County (AZ)	Thomes E Dobbs (Mississippi State Department of Health)
County of San Diego Health and Human Services Agency	Maryland Department of Health	University of Kentucky Research Foundation
Cuyahoga County Board of Health (OH)	Michigan Department of Health and Human Services	Utah Department of Health
Delaware Department of Health and Social Services	Minnesota Department of Health	Vermont State Agency of Human Services
District of Columbia Department of Health	Missouri Department of Health and Senior Services	Virginia Department of Health
Florida Department of Health	Montana Department of Public Health and Human Services	Washington State Department of Health
Florida Department of Health in Broward County (FL)	Nebraska Dept of Health and Human Services	West Virginia Department of Health and Human Resources
Florida Department of Health in Duval County	Nevada Department of Health and Human Services	Wisconsin Department of Health Services
Florida Department of Health, Palm Beach County (FL)	New Hampshire Department of Health and Human Services
Franklin County Board of Commissioners/Public Health (OH)	New Jersey Department of Health
Fund for Public Health in New York, Inc. (NYC Health)	New Mexico Department of Health

Which of the following best describes your role on the OD2A team?

(Please choose only one – drop down list)

Create drop down list of key roles

[For direct TA activities only] Who was the provider of the technical assistance activity listed in your invitation email?

(Please choose only one – drop down list)

Create drop down list of TA providers

This survey is referring to the specific TA activity listed in your invitation email. Please select the response that best represents your rating for this TA activity for each of the following questions.

	Poor	Fair	Good	Very Good	Excellent
Please rate the overall quality of this activity.
	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
My knowledge and/or skills increased as a result of this activity.
The information and materials shared were useful to my work.
The length and pace of the activity was appropriate.
The materials and information were appropriate for my level of experience and knowledge.
The knowledge and expertise of this trainer/presenter were appropriate for this activity.
Additional Items for Webinars
The webinar met the following objectives: <insert specific webinar objectives>
The webinar technology provided a positive learning environment.
The event connected us with the appropriate peers/agencies.
Additional Items for Peer-to-Peer Exchange Sessions
The event connected us with the appropriate peers/agencies.
The event gave access to subject matter experts.
Additional Item for In-Person Training/Site Visit
The training met the stated objectives: <insert specific training objectives>
Additional items for ALL group TA Events
Participation and interaction were encouraged.
The overall quality of the event met my expectations.

OPEN ENDED QUESTIONS

How do you plan to apply the information from this activity to your work?

What was MOST valuable about the activity in which you participated?

What was LEAST valuable about the activity in which you participated?

What suggestions do you have for improving training and technical assistance activities?

What additional technical assistance needs do you or your organization have?

Thank you for your participation!