4 (Revised) Community of Practice Session Assessment

OMB Number: 0915-0391

Expiration Date: 7/31/2026

Public Burden Statement: To judge performance against goals, HRSA HAB will administer technical assistance evaluation surveys following TA and training, webinars, teleconferences, and meetings. Findings will drive quality improvement activities and reports. 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.

4. Communities of Practice Session Assessment Instrument

Instructions:

To measure the effectiveness of the (insert date) Community of Practice (CoP) learning session, we invite you to complete this survey.

The survey will take about 5 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 improve the CoP learning sessions.

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?

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

No

Effective

2. What is your age?

Please indicate the extent to which you agree with the following statements about today’s session.	(4) = Strongly Agree	(3) = Agree	(2) = Disagree			(1) = Strongly Disagree
6. My learning expectations were met.
7. I am satisfied with the quality of staff leading the session.
8. The content was engaging.
9. Facilitators were responsive to participants’ comments and questions.
10. The material presented was useful to me.
11. I expect that the session will benefit my patients.
12. I am satisfied with my experience.

Please rate the effectiveness of the following:	(4) = Very Effective	(3) = Effective	(2) = Somewhat Effective			(1) = Not at all			(0) = Not Applicable
13. Facilitator-led presentations and PowerPoint slides
14. Videos
15. Practices
16. Report outs
17.Group discussions