Form 1 Assessment and Capacity Building Plan Satisfaction Surve

OMB Control No.: xxxx-xxxx

Expiration Date: xx/xx/20xx

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 4 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. 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.

Assessment and Capacity Building Plan Satisfaction Survey

Assessment

Please answer the following questions about the assessment product.	Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree
Partnership
The assessment summary was shared with us in a timely way.
The assessment summary reflects the discussions we had with the Center representatives.
As a group, the representatives from the Center(s) helped us connect the assessment recommendations to potential capacity building services.
Liaison Effectiveness
As a group, the representatives from the Center(s) were knowledgeable and informed about our State/Tribe.
As a group, the representatives from the Center(s) were effective facilitators during the assessment process.
As a group, the representatives from the Center(s) communicated with us in a way that felt relevant to the values and context of our agency/tribe/court.
As a group, the representatives from the Center(s) effectively guided us through the assessment process.
Accuracy
The assessment summary was clear and understandable.
The assessment process accurately identified our State’s/Tribe’s capacity building needs.
The assessment summary added to our understanding of our system.
General Satisfaction
Overall, I was satisfied with the assessment process.

General Satisfaction (Cont.)

Could your experience with the Center(s) have been improved? (Circle One)

YES NO

If yes, please describe how your experience with the Center(s) could have been improved.

Capacity Building Plan

Please answer the following questions about the Capacity Building planning process.	Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree
Cultural Fit
This capacity building planning process was flexible to meet the needs of our agency/tribe/court.
Our agency/tribe/court’s values and practices were respected during the capacity building planning process.
In general, this process reflected how people from our agency/tribe/court work together to accomplish something.
The steps in the capacity building planning process were appropriate for the systems change work we are doing.
Liaison Effectiveness
The steps in the capacity building planning process were clearly communicated by Center representatives to our staff and stakeholders.
As a group, the representatives from the Center(s) communicated with us in a way that felt relevant to the values and context of our agency/tribe/court.
As a group, the representatives from the Center(s) effectively guided us through the capacity building planning process.
As a group, the representatives from the Center(s) helped us to assess readiness and identify possible barriers that must be addressed.
Our agency/tribe/court was able to develop a strong capacity building plan with the support of the Center representatives.
Capacity Building Plan Effectiveness
The theory of change and logic model for our capacity building plan provide a clear plan for moving forward.
The capacity building plan identified where we need to achieve better outcomes.
The capacity building plan is realistic for our agency/tribe/court.
The capacity building plan will be an effective tool for helping our agency/tribe/court achieve our outcomes.
General Satisfaction
Overall, I was satisfied with the process to develop the capacity building plan.
Overall, I was satisfied with the capacity building plan itself.

General Satisfaction (Cont.)

Could your experience with the Center(s) have been improved? (Circle One)

YES NO

If yes, please describe how your experience with the Center(s) could have been improved.