2 Attachment B_Individualized Targeted TA Closeout

OMB No: 0915-0212

Expiration date: 04/30/2024

Individualized (Targeted) TA Closeout

Sent after each Closeout Report Submission

Public Burden Statement: The purpose of this information collection request is to assess participant satisfaction with various training and TA activities offered through a contracted TA provider, the Education Development Center. 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. This data collection is voluntary. The OMB control number for this project is 0915-0212 and is valid until 04/30/2024. Public reporting burden for this collection of information is estimated to average .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.

1. Overall, how satisfied are you with the targeted technical assistance you received from TARC?

   1. Extremely satisfied

   2. Satisfied

   3. Dissatisfied

   4. Extremely dissatisfied

2. [If chosen “Dissatisfied” or “Extremely dissatisfied”] Please explain why you were dissatisfied with the TA request: [Open text]

3. Below are the objectives created during the TA request by you and your TA Specialist(s). Please indicate the extent to which you agree that these objectives were met: [Matrix]

   1. Objective [Objectives are identified at the beginning of a Level 2 or 3 TA occurrence by both the awardee and the TA Specialist. They are documented in the Closeout Report. The language here will be tailored to the individual objectives of that closeout report, but we do not expect to have more than 1-3 objectives per closeout report.]

   2. Objective [Objectives are identified at the beginning of a Level 2 or 3 TA occurrence by both the awardee and the TA Specialist. They are documented in the Closeout Report. The language here will be tailored to the individual objectives of that closeout report, but we do not expect to have more than 1-3 objectives per closeout report.]

4. Have you taken any action steps as a result of the TA received?

   1. Yes

   2. No

5. [If yes] Please describe 1-2 action steps you have taken as a result of the TA request: [Open text]

6. [If no] Please describe how we could have better supported you in taking action steps [Open text]

7. Please select the extent to which you agree with the following statements [Matrix]:

   1. My TA providers and I have a good relationship.

   2. My TA providers and I work together on setting goals for TA requests.

   3. My TA providers understand what I/my team is trying to accomplish with TA requests.

   4. My TA providers and I agree on what is important for me/my team to work on.

8. What aspects of the TA provided were most useful? [Multiple Choice]

   1. Assist awardee with identifying needs

   2. Site visit

   3. Create training opportunity

   4. Provide peer examples

   5. Connect awardee with peers

   6. Review document/submission

   7. Facilitate conversations

   8. Hold strategic planning session

   9. Provide resource/strategy

   10. Other, please comment: (Open text)

9. How can we improve future TA requests? [Open text]

10. We are particularly interested in whether this TA was provided in a culturally appropriate manner. Please rate your agreement with the following statement: This TA was provided in a culturally responsive manner (respectful of individual beliefs, language, perspectives, and needs)

    1. Strongly agree

    2. Agree

    3. Disagree

    4. Strongly disagree

11. As we work to improve our technical assistance, would you be willing to speak with us if we wanted to follow up on some of the feedback that you provided (we would simply contact you via email)?

    1. Yes, I would be willing to speak with you

    2. No, I would prefer not to