Form #3 Form #3 Individual TA Evaluation

A HRQ Complex Patient Research

Individual Technical Assistance Evaluation

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Individual Technical Assistance topic:

Date of initial request:

1. The technical assistance I received in response to my request…

___ did not meet my expectations

___ met my expectations

___ exceeded my expectations

2. I received a timely response to my request for technical assistance.

1	2	3	4	5	6	7	8	9	10
Completely Disagree					Completely Agree

3. The technical assistance I received provided me with the information I needed to adequately answer my questions/resolve my issue.

1	2	3	4	5	6	7	8	9	10
Completely Disagree					Completely Agree

4. The person(s) responding to my request for technical assistance had the knowledge and expertise to deliver the information in an effective manner.

1	2	3	4	5	6	7	8	9	10
Completely Disagree					Completely Agree

5. I gained information and knowledge through this technical assistance that will be helpful in my research.

1	2	3	4	5	6	7	8	9	10
Completely Disagree					Completely Agree

6. I am likely to make changes to my research (study design/ protocol/ implementation/ analysis/ results interpretation) because of information or knowledge I gained from this technical assistance.

1	2	3	4	5	6	7	8	9	10
Completely Disagree					Completely Agree

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. 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.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

7. Please tell us how this individual technical assistance could have been better:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

8. Other comments:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

2