1 Instrument A MIECHV Site Visit Compliance Review Awardee

OMB Control No. 0915-0212

Expiration Date: 04/30/2024

Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program Site Visit Compliance Review

Awardee Feedback Form

OMB Control No. 0915-0212

Expiration Date: 04/30/2024

Public Burden Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is [0915-0212]. This information collection is to support the Maternal, Infant, and Early Childhood (MIECHV) program for site visit compliance review. This information will be used to collect feedback for possible future improvements. The time required to complete this information collection is estimated to average less than [# minutes/hours] per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is voluntary and will be used for future program improvements]. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: HRSA Information Collection Clearance Officer, Room 14N39, 5600 Fishers Lane, Rockville, Maryland 20857 or paperwork@hrsa.gov, Attention: Information Collections Clearance Officer.

Introduction Letter

* ^1. Dear Awardee,

Thank you for participating in the recent HRSA MIECHV Compliance Review site visit. To continuously improve our processes, we would like to get your feedback on the site visit and the staff assigned to the site visit. This survey will allow us to gather feedback and report any successes, recommendations for improvement, and/or challenges to HRSA immediately.

Your feedback helps us review our processes, assess our staff, and make any necessary improvements. Your responses are anonymous to HRSA, and the survey should take less than 15 minutes to complete. Please complete it within 5 business days of the date of receipt. If you have questions about the survey please contact the Project Manager, [name, email, phone number]. We look forward to your feedback.

The dropdown box above will list the current HRSA project officer’s names.

Pre-Site Visit

This section is an evaluation of the pre-site visit activities that occurred in preparation for your site visit. When answering these questions please think specifically about the planning phase of the site visit.

* ^{2. Did you participate in a pre-site visit conference call?}

Yes No

• ^{3. The planning for the site visit was timely and responsive to our needs.}

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^{4. The pre-site visit planning calls helped us prepare for the site visit.}

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^5. The Site Visit Readiness Checklist helped us prepare for the site visit.

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• 6. ^{The Site Visit Assessment Tool helped us prepare for the site visit.}

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^{7. Expectations of the site visit were clearly articulated.}

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• 8. Please provide any additional comments/ recommendations about the pre-site visit process.

Site Visit – Programmatic Consultant

This section is an evaluation of the programmatic consultant assigned to your site visit. When answering these questions please think specifically about that member of the site visit team.

• ^{9. Site Visit Staff:}

  

• Who is the Programmatic Consultant that visited you?

The Programmatic Consultant…

• ^{10. Exhibited appropriate knowledge of MIECHV programs.}

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^{11. Was well prepared, demonstrated knowledge of our organization, the Site Visit Assessment} Tool and the HRSA site visit process.

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^{12. Was objective and professional}

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^{13. Effectively utilized the Site Visit Assessment Tool and the} probing ^{questions to frame the discussion and} to add clarity to the items being assessed.

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

14. Please provide any additional comments concerning the programmatic consultant.

Site Visit - Fiscal Consultant

This section is an evaluation of the fiscal consultant assigned to your site visit. When answering these questions please think specifically about that member of the site visit team.

• ^{15. Site Visit Staff:}

• Who is the Fiscal Consultant that visited you?

The Fiscal Consultant…

• ^{16. Exhibited appropriate knowledge of MIECHV programs}

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^{17. Was well prepared, demonstrated knowledge of our organization, the Site Visit Assessment} Tool and the HRSA site visit process.

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^{18. Was objective and professional.}

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^{19. Effectively utilized the Site Visit Assessment Tool and the probing questions to frame the discussion and to} add clarity to the items being assessed.

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• 20. Please provide any additional comments concerning the fiscal consultant.

^{Site Visit - Notetaker}

^{This section is an evaluation of the notetaker assigned to your site visit. When answering these questions please think specifically about that member of the site visit team.}

• ^{21. The notetaker demonstrated professionalism in supporting the site visit.}

^{Disagree Strongly Disagree Undecided Agree Strongly Agree N/A}

• ^{22. Please provide any additional comments concerning the notetaker.}

^{Site Visit} - Other Issues

• ^{23. The site visit debriefing provided an accurate account of the discussions during the site visit.}

Disagree Strongly Disagree Undecided Agree Strongly Agree N/A

• ^{24. What were the most significant challenges you encountered during the site visit? Check all that apply.}

• ^{Document Requests}

• ^{Technology (Please describe: ______________)}

• ^{Staff or Partners Not Available}

• ^{Limited Time for Discussions with Consultants and HRSA Staff}

• ^{Meeting Days Too Long}

• ^{Meeting Days Too Short}

• ^{Virtual Visit / Challenges of Virtual Participation}

• ^{Other (Please describe: ______________)}

• ^{No Challenges}

Site Visit - Other Issues

• 25. What worked well during the site visit?

• 26. Please provide any additional comments about the site visit process.

^{Thank you for completing this survey! If you have additional comments or questions about this survey please contact the Project Manager, [name, email, phone number].}

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