Tribal Maternal, Infant, and Early Childhood Home Visiting (TMIECHV) Regional Meetings Feedback Forms

Appendix D

OMB Control No. 0970-0401

Expiration Date: 06/30/2024

[insert date and title] Virtual Tribal Regional Individual Session Feedback Form

Please select the role that most closely aligns with your responsibilities related to the MIECHV project.

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

Home Visitor Consultant Other

Please rate each session using the scale listed below.

Strongly Disagree Disagree		Slightly Disagree Slightly Agree				Agree Strongly Agree
Please indicate the degree (enter rating 1, 2, 3, 4, 5 or 6 in the box) to which the Plenary or Breakout session...	Achieved intended objectives		Met your needs	Provided new information	Allotted time for questions and/or quality discussion		Was well organized, engaging and effectively presented	Speaker(s) demonstrated topic expertise	Provided information that you can apply to practice and/or enhanced your professional expertise
Session date, title, and presenter

What is one thing that you liked best about the session?

What is one thing that you would change?

Other comments:

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 Tribal Maternal, Infant, and Early Childhood Home Visiting regional meetings. Public reporting burden for this collection of information is estimated to average 3 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.

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