2 (Revised) Community of Practice Pre-Assessment

OMB Number: 0915-0391

Expiration Date: 7/31/2026

Public Burden Statement: The evaluation focuses on process and impact evaluation of all CoP Teams. The information collected will inform satisfaction measures (reaction), change in knowledge after the TA (learning), and change in behavior or practice after the introduction of evidence-based interventions (behavior). 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 0915-0391 and it is valid until 7/31/2026. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 0.13 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 14NWH04, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

2. Communities of Practice Pre-Assessment Instrument

Instructions:

To measure the effectiveness of the [insert name of community of practice] Community of Practice (CoP), we invite you to complete this survey. We will ask you to complete another survey after the last CoP session.

The survey will take about 17 minutes to complete.

Your identifying information and survey responses are confidential and will only be seen by the evaluation team. Individual responses will be combined with responses from all other survey participants for reporting purposes. Your honest responses will help us assess the effectiveness of the CoP learning sessions and understand how they may be improved.

1. Type of employment organization: (check one) Local/State Government Agency

Tribal Organization

Outpatient Behavioral Health Agency Community Health Center FQHC/FQHC look-alike

University Medical Center/Hospital Faith-based Organization

AIDS Service Organization (ASO) Other

2. Position Title:

3. How long have you been in your current position?

4. In your current position, do you work directly with patients? Yes

No

5. What is your age?

6. What are your overall expectations for the CoP as it moves forward?

6. Are there any specific issues or topics that you would like to have discussed as part of the CoP?

6. What would you like to achieve by the end of the CoP?

For the Youth Moving into Adult Care Community of Practice participants ONLY:

We are interested in how the CoP will impact you personally. How confident are you that…	(5) =Very Confident	(4) = Confident	(3) = Undecided	(2) = Somewhat Confident	(1) = Not Confident
9. Your participation will expand your collaborative network?
10. Your participation will produce new knowledge in youth transferring to adult care to help you in your work?
11. Your participation will change the way you conduct your work over the next year?
12. Your participation will increase your capacity to conduct your work?
13. Your participation in the CoP will increase opportunities to learn new information?
14. Your participation in the CoP will increase opportunities to learn new ways of doing your job?
15. Your participation in the CoP will increase opportunities to learn new evidence-based, evidence-informed, or emerging interventions/practices?
16. The CoP will meet its goals?
17. You will be able to develop productive collaborations within the CoP?

We are interested in how you think the CoP will impact the way you do your work. Please tell us about your expectations.	(5) = Greatly	(4) = Somewhat	(3) = Undecided	(2) = Very Little	(1) = Not At All
18. My knowledge of youth integration will increase.
19. My knowledge of best practices will increase.
20. My learning expectations will be met.
21. My work is likely to change as a result of my experience with the CoP.
22. My networking experiences will increase.
23. I will take action on ideas that were generated as a result of my work with the CoP.

We are interested in your current abilities in your work with patients. How would you rate your current ability to:	(5) = Very High	(4) = High	(3) = Medium	(2) = Low	(1) = Very Low	(0) = Not Applicable
24. Serve youth moving to adult care?
25. Work with multidisciplinary Team members to transfer youth?
26. Help prepare youth to move to an adult clinic?

Disagree

Applicable

Please indicate how strongly you agree or disagree with the following statements.	(4) = Strongly Agree	(3) = Agree	(2) = Disagree	(1) = Strongly Disagree	(0) = Not Applicable
27. I feel confident in my ability to create transfer plans with youth, families, and staff.
28. I do not feel confident addressing barriers to a successful transfer such as insurance eligibility, youth readiness, and inter-clinic communication.

Please indicate how strongly you agree or disagree with the following statements about the agency/organization where you work.	(4) = Strongly Agree	(3) = Agree	(2) = Disagree	(1) = Strongly Disagree
29. Our facility has formal transfer policies and protocols.
30. At my facility, the transfer process enhances the patient’s autonomy and increases their capacity for self-care and self-advocacy.
31. Overall, leadership is supportive of efforts to promote inter-clinic communication and data sharing.

Please indicate how strongly you agree or disagree with the following statements.	(4) = Strongly Agree	(3) = Agree	(2) = Disagree	(1) = Strongly	(0) = Not
32. I have a good understanding of the challenges of moving youth to adult clinics.
33. I am knowledgeable about strategies to help prepare youth for a successful transfer.
34. I have integrated strategies to successfully integrate youth into my practice.