10 Individualized Targeted TA

OMB No: 0906-0084

Expiration date: 02/28/2027

Individualized (Targeted) TA Closeout

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. Public reporting burden for this collection of information is estimated to average .12 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 the targeted technical assistance (TA) 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. How can we improve future TA requests? [Open text]

9. Please rate your agreement with the following statement: This TA request integrated diversity, equity, and inclusion into the content it provided.

   1. Strongly agree

   2. Agree

   3. Disagree

   4. Strongly disagree

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 TA to more intentionally integrate diversity, equity, and inclusion.

12. As we work to improve our TA requests, 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.

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