3 (revised) Community of Practice Post-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.

3. Communities of Practice Post-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.

The survey will take about 23 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. 

   Disagree

   What is your age?

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

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
6. Serve youth moving to adult care?
7. Work with multi-disciplinary Team members to transfer youth?
8. Help prepare youth to move to an adult clinic?

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
9. I feel confident in my ability to create transfer plans with youth, families, and staff.
10. 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) =	(1) = Strongly Disagree
11. Our facility has formal transfer policies and protocols.

Greatly

Undecided

Very Little

12. At my facility, the transfer process enhances the patient’s autonomy and increases their capacity for self-care and self-advocacy.
13. 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 Disagree	(0) = Not Applicable
14. I have a good understanding of the challenges of moving youth to adult clinics.
15. I am knowledgeable about strategies to help prepare youth for a successful transfer.
16. I have integrated strategies (to successfully integrate youth into my practice).

We are interested in what you think about the CoP and how participation has impacted you personally. Please tell us about your experience.	(5) =	(4) = Somewhat	(3) =	(2) =	(1) = Not At All
17. I am satisfied with my experience.
18. My collaborative network expanded.
19. My knowledge of youth integration increased.
20. My knowledge of best practices increased.
21. My capacity to perform my work increased.
22. Participation provided new ways of doing my job.
23. The CoP met its goals.
24. My ability to develop productive collaborations increased.
25. My learning expectations have been met.
26. My networking experiences increased.
27. My work changed as a result of my experience.
28. I will take action on ideas that were generated as a result of my work with the CoP.

29. As a result of the CoP, did your facility implement a new evidence-based, evidence-informed, or emerging intervention/practice?

Yes (continue to 33) No (skip to 35)

Don’t Know/Not Sure (skip to 35)

29. What is the name of the intervention or practice that was implemented?

29. How closely did you adhere to the standard program or intervention model?

To a Great Extent Somewhat

Very Little Not at All

_Don’t Know/Not Sure

We would like to have a deeper understanding of your experiences. Please respond to the following questions:

29. What was the most effective part of the CoP?

29. What did you learn that will help you perform better in your role?

29. How have you put what you learned in this CoP to use?

29. Has participation in this CoP resulted in changes in your collaborations or partnerships? If so, please describe.

29. Has participation in this CoP helped you achieve your goals related to (youth integration)? Why/why not?

29. How can Bizzell improve the implementation of CoP?