6 Foundational TA Assessment

OMB Number: 0915-XXXX

Expiration Date: 12/31/2026

Public Burden Statement: To judge performance against goals, HRSA HAB will administer technical assistance evaluation surveys following TA and training, webinars, teleconferences, and meetings. Findings will drive quality improvement activities and reports. 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 information collection is 0915/0906-XXXX and it is valid until 12/31/2026. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 0.08 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 or paperwork@hrsa.gov.

6. Foundational TA Assessment Instrument

Instructions:

To measure the effectiveness of the technical assistance we provided on (insert date), we invite you to complete this survey.

The survey will take about 4 minutes to complete.

Your identifying information and survey responses are confidential and will only be seen by the evaluation team. Individual responses will be combined with responses from all other survey participants for reporting purposes. Your honest responses will help us understand how the technical assistance may be improved.

1. Type of employment organization: (check one)
Local/State Government Agency
Tribal Organization
Outpatient Behavioral Health Agency
Community Health Center
FQHC/FQHC look-alike
University Medical Center/Hospital
Faith-based Organization
AIDS Service Organization (ASO)
Other

2. Position Title: ___________________________

3. How long have you been in your current position? ___

4. In your current position, do you work directly with patients?

Yes

No

5. What is your age? _____

6. What is your gender identity?

Woman
Man
Transgender
Non-binary
Other

7. Are you Hispanic or Latino?

Yes

No

8. What do you consider yourself to be? (Select one or more.)

Alaska Native

American Indian

Asian

Black or African American

White/Caucasian

Native Hawaiian or Other Pacific Islander

Other

Please indicate your agreement with these statements about the technical assistance materials:	(5) = Strongly Agree	(4) = Agree	(3) = Neutral	(2) = Disagree	(1) = Strongly Disagree
9. The materials were responsive to my request.
10. The materials provided will be useful to me.
11. The materials enhanced my skills in this topic area.
12. The materials are relevant to my career.
13. I expect to use the information gained from this technical assistance.
14. I am satisfied with the quality of the technical assistance materials.

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