Form 1 Communities of Practice

I TSN Feedback Form

Communities of Practice

TITLE OF INFORMATION COLLECTION: State Capacity Building Center Targeted Technical Assistance Feedback Collection for Communities of Practice

OMB Control No: 0970-0401

Expiration date: 05/31/2021

This form will go out to participants once annually during the federal fiscal year. The survey is intended to assess the Communities of Practice after they are established and have had three meeting. Surveys for the fiscal year must be complete by July 31 of the fiscal year, which means that surveys should be going out in time for inclusion in the annual evaluation report for the SCBC.

Instructions

The State Capacity Building Center is collecting feedback regarding its technical assistance (TA) services. According to our records, you recently participated in the State Capacity Building Center [NAME OF EVENT]. We would greatly appreciate your input and will use your feedback to inform future technical assistance efforts. To provide feedback, please respond using this form. The brief voluntary survey will only take a few minutes and all responses are anonymous.

NOTE: THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13). Public reporting burden for this collection of information is estimated to average 8 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.

Technical Assistance Activity: [NAME OF EVENT]
Event Date: [DATE OF EVENT]

Please select your role:

• Community member

• Direct child-serving practitioner (e.g., child care, preschool, home visiting, teacher)

• Family member

• State-level professional

• Training and technical assistance professional

• Other. Please describe: _________________________________________

Please indicate the extent to which you agree with the statements below.		Strongly Agree	Agree	Disagree	Strongly Disagree	Not Applicable
Community of Practice	The purposes of the community of practice were clear.	1	2	3	4	N/A
	Resources were provided as needed.	1	2	3	4	N/A
	The experience of being in the community of practice was useful (i.e. provided you with practical information or a practical perspective to inform your work).	1	2	3	4	N/A
	The experience of being in the community of practice was relevant to my current work (i.e., pertinent to your current work).	1	2	3	4	N/A
	The experience of being in the community of practice was influential (i.e., influenced your thinking; gave you “a-ha” moments; enabled you to think in a different way about your system(s), your partnerships, or other critical aspects of your work; and/or helped you analyze, synthesize, or integrate information in a new way.)	1	2	3	4	N/A
Facilitators	The facilitator was well prepared	1	2	3	4	N/A
	The facilitator helped the group value the contributions of each member.	1	2	3	4	N/A
	The facilitator helped guide discussions and shared activities about our shared interest.	1	2	3	4	N/A
Participant	I increased my awareness and knowledge by participating in the community of practice.	1	2	3	4	N/A
	I feel ready to apply new resources or ideas shared to my work.	1	2	3	4	N/A
	Overall, the event was relevant and fit my needs	1	2	3	4	N/A

If you marked disagree or strongly disagree above or if you have any comments, please take a moment to give us a little more information.

What factors if any, may prevent you from using what you learned in the Community of Practice sessions in your work? (Please check ALL that apply)

□ What I’ve learned in the sessions is not applicable to my work

□ Lack of time

□ Limited funds or other resources to support this effort

□ Lack of state policies or processes to support this effort

□ Lack of support/guidance from state leadership

□ Limited or no stakeholder buy-in

□ I don’t have the authority or influence to gain support for this effort

□ Other (Please describe):______________

Which aspect(s) was most useful for you and why?

How could we improve this work to better meet your needs?

What other topics for technical assistance would be useful to you?

Thank you for participating!

Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to collect participant feedback to shape future OCC technical assistance services. Public reporting burden for this collection of information is estimated to average 8 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. The OMB number and expiration date for this collection are OMB #:. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Carrie Kocot at carolyne.kocot@icf.com.

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