3 Practicum Check In Survey

OMB No: 0906-0084

Expiration date: 02/28/2027

CQI Practicum (Check in) Survey

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. The OMB control number for this project is 0906-0084 and is valid until 02/28/2027. This information collection is voluntary. All responses will be aggregated and respondents will remain confidential. 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

1. Overall, how satisfied are you with CQI Practicum?

   1. Very satisfied

   2. Satisfied

   3. Dissatisfied

   4. Very dissatisfied

2. [If chosen “Dissatisfied” or “Very dissatisfied”] Please explain why you are dissatisfied with the CQI Practicum: [Open text]

3. How likely are you to use the information or ideas that you learned in the Practicum thus far in your work?

   1. Very likely

   2. Likely

   3. Unlikely

   4. Very unlikely

4. [If Unlikely/Very unlikely] Please explain how we could improve the CQI Practicum information to be more relevant to your work. [Open text]

5. How supportive has the CQI Practicum been thus far in helping your team work towards this goal/these goals identified on your team’s application? [Insert goals that teams identified on their application]

1. Very supportive

2. Supportive

3. Mildly supportive

4. The CQI Practicum is not supporting us in reaching our goals

6. [If mildly or not at all supportive] Please explain why the CQI Practicum has not been supported your team in working towards this goal. [Open text]

7. Thus far into the Practicum, have you experienced any barriers to participating in the CQI Practicum, including participating in the coaching calls, virtual sessions, or on the MALL?

1. Yes, I’ve experienced barriers

2. No, I’ve not experienced any barriers

8. [If yes] Please describe the barriers you experienced that kept you from participating fully in the CQI Practicum: [Open text]

9. When are you MOST engaged in the CQI Practicum?

1. Main virtual sessions

2. Breakouts during virtual sessions

3. Team coaching calls

4. Other, please explain: _____

10. To what extent did you see diversity, equity, and inclusion show up in the approach of the TA provided?

    1. To a great extent

    2. Somewhat

    3. Very little

    4. Not at all

11. Please comment with any suggestions for how we can improve our technical assistance to more intentionally integrate diversity, equity, and inclusion.

12. Is there anything else you would like to tell us about your experiences with the CQI Practicum that we haven’t asked? [Open text]

13. As we work to improve our CQI Practicums, would you be willing to speak with us if we wanted to follow up on some of the feedback you provided (we would contact you via email)?

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

    2. No, I would prefer not to.

14. [If yes] Please provide your email [Open text]