2 Post-TA Activity Survey

OMB Number: 0906-0084

Expiration Date: 02/28/2027

Public Burden Statement: The purpose of this collection is to assess the usability, relevance, and effectiveness of a technical assistance (TA) resource developed to expand health center awareness of sexual assault-related health care needs among users including health care providers, community advocates, and health care administrators. This evaluation will also assess the utilization, reach, and engagement of dissemination materials and the impact of public and on-demand TA activities. 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 information collection is 0906-0084 and it is valid until 2/28/2027. This information collection is voluntary. Data will be private to the extent permitted by the law. Public reporting burden for this collection of information is estimated to average 11 minutes 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 14NWH04, Rockville, Maryland, 20857 or paperwork@hrsa.gov.  Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement. 

Post-TA Activity Survey

Introduction

ICF, under contract with the Health Resources and Services Administration (HRSA), manages and evaluates the Expanding Health Center Awareness of Sexual Assault-Related Health project. This survey is to gather your feedback regarding the perceived quality and effectiveness of the technical assistance (TA) offered to support the use of the TA Resource. Our goal is to provide the best assistance to support your work and this feedback will help us to make that TA better. The survey is designed to take about 5 minutes to complete.

Informed Consent

Your participation is voluntary. You may refuse to answer any questions or stop the survey at any time.

ICF will have access to your contact information when you complete this survey. However, ICF will

aggregate and de-identify responses when reporting to HRSA. ICF will not link your name with your

individual responses in any reports to HRSA. ICF will maintain your responses in a secure manner.

There are no right or wrong answers or ideas—we want to hear your experiences and opinions.

There are no risks to you or your organization for participating in this survey. The information will be

used to improve the training and TA provided to HRSA-funded health centers. This survey will take no longer than five minutes to complete.

For questions regarding your rights related to survey participation, you can contact ICF’s Institutional Review Board (IRB) at IRB@icf.com.

* I confirm that I have read the information above and agree to participate in the survey.

Agree, continue to the survey

Draft Survey

Feedback on “Name of TA Activity”

1. Please indicate the name of the HRSA-funded health center you are affiliated with:

   1. [Open text field]

2. Which of the following best describes your role(s) at the HRSA-funded health center (select all that apply):

   1. Clinical staff (i.e., front desk, medical assistant, etc.)

   2. Clinical provider (i.e., physician, nurse practitioner, SAFE examiner, etc.)

   3. Health center administration (i.e., Medical Director, Director of Patient Services)

   4. Patient navigator

   5. Community health worker

   6. Other (please specify): __________________

3. How did you learn about [Name of TA Activity]?

   1. Social media (LinkedIn, Instagram, X, etc.)

   2. Colleagues at my organization

   3. Colleagues from another organization

   4. HRSA Newsletter

   5. Conference

   6. Other: [OPEN TEXT]

This survey is referring to the specific TA activity listed in the email. Please select the response that best represents your rating for this TA activity for each of the following questions.

	Poor	Fair	Good	Very Good	Excellent
Please rate the overall quality of this activity.
	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
My knowledge and/or skills increased as a result of this activity.
The information and materials shared were useful to my work.
The length and pace of the activity was appropriate.
The materials and information were appropriate for my level of experience and knowledge.
The knowledge and expertise of this trainer/presenter were appropriate for this activity.
Additional Items for Public TA Activities
The [insert type of public TA activity] met the stated objectives:
TA activity objective 1
TA activity objective 2
TA activity objective 3
TA activity objective 4
TA activity objective 5
The [insert type of public TA activity] technology provided a positive learning environment.
The event connected us with the appropriate peers/agencies.
Additional Items for On-Demand TA Activity
The on-demand TA activity met the following objectives:
TA activity objective 1
TA activity objective 2
TA activity objective 3
TA activity objective 4
TA activity objective 5
Participation and interaction were encouraged.
This TA activity incorporated the local context into the training.

Open text field

How do you plan to apply the information from this event to your work?

What was MOST valuable about this event?

Open text field

Open text field

What was LEAST valuable about this event?

Open text field

What suggestions do you have for improving training and technical assistance events?

Open text field

What additional technical assistance needs do you or your organization have?