Tribal Maternal, Infant, and Early Childhood Home Visiting (TMIECHV) Program Training and Technical Assistance Immediate Feedback Form

Appendix A

OMB Control No. 0970-0401

Expiration Date: 06/30/2024

Tribal Maternal, Infant, and Early Childhood Home Visiting Program Training and Technical Assistance Immediate Feedback Form

(administered after each Training or TA occurrence)

Please select the role that most closely aligns with your responsibilities related to the Tribal Home Visiting project.

Grantee Lead/Director/Coordinator Grantee Data/Evaluation Staff Grantee Program Staff/Consultant

Grantee Grants Management/Fiscal Staff Home Visitor

Please rate items 1-6

TA met my needs
This TA effectively met your needs.		This TA provided productive ways of learning.
This TA was engaging.		TA on this topic was delivered at a time when it was relevant for your program.
This TA met the intended goals/objectives.		TA offered options for next steps, ideas, or action items that can be applied soon.

TA facilitated new learning in the following areas:		I am planning on applying what I learned in the following areas:
Tribal/Organizational Leadership Support, Governance, and Administration		Tribal/Organizational Leadership Support, Governance, and Administration
Quality Workforce		Quality Workforce
Fidelity Monitoring / Model Fidelity		Fidelity Monitoring / Model Fidelity
Community and Partner Engagement		Community and Partner Engagement
Recruitment, Enrollment, and Engagement of Families		Recruitment, Enrollment, and Engagement of Families
Dissemination		Dissemination
Early Childhood Systems Building		Early Childhood Systems Building
Policies and Procedures		Policies and Procedures
Sustainability		Sustainability
Other topics (as applicable)		Other topics (as applicable)
(7) Other feedback

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, ACF is gathering information to assess the quality and outcomes of Training and Technical Assistance events. Public reporting burden for this collection of information is estimated to average 2 minutes per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0401, and the expiration date is 06/30/2024. If you have any comments on this collection of information, please contact Anne Bergan, Office of Early Childhood Development, Administration for Children and Families, HHS, Mary E. Switzer Building 330 C Street SW, Suite 3014F, Washington, DC 20024.