2 Community of Practice Pre-Assessment

OMB Number: 0915-XXXX

Expiration Date: 12/31/2026

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 0915/0906-XXXX and it is valid until 12/31/2026. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 0.28 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 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

2. Community of Practice Pre-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. We will ask you to complete another survey after the last CoP session.

The survey will take about 17 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. What is your age? _____

6. What is your gender identity?

Woman
Man
Transgender
Non-binary
Other

7. Are you Hispanic or Latino?

Yes

No

8. What do you consider yourself to be? (Select one or more.)

Alaska Native

American Indian

Asian

Black or African American

White/Caucasian

Native Hawaiian or Other Pacific Islander

Other

9. What are your overall expectations for the CoP as it moves forward?

10.Are there any specific issues or topics that you would like to have discussed as part of the CoP?

11. What would you like to achieve by the end of the CoP?

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

We are interested in how the CoP will impact you personally. How confident are you that…	(5) =Very Confident	(4) = Confident	(3) = Undecided	(2) = Somewhat Confident	(1) = Not Confident
12. Your participation will expand your collaborative network?
13. Your participation will produce new knowledge in youth transition to help you in your work?
14. Your participation will change the way you conduct your work over the next year?
15. Your participation will increase your capacity to conduct your work?
16. Your participation in the CoP will increase opportunities to learn new information?
17. Your participation in the CoP will increase opportunities to learn new ways of doing your job?
18. Your participation in the CoP will increase opportunities to learn new evidence-based, evidence-informed, or emerging interventions/practices?
19. The CoP will meet its goals?
20. You will be able to develop productive collaborations within the CoP?

We are interested in how you think the CoP will impact the way you do your work. Please tell us about your expectations.	(5) = Greatly	(4) = Somewhat	(3) = Undecided	(2) = Very Little	(1) = Not At All
21. My knowledge of youth transition will increase.
22. My knowledge of best practices will increase.
23. My learning expectations will be met.
24. My work is likely to change as a result of my experience with the CoP.
25. My networking experiences will increase.
26. I will take action on ideas that were generated as a result of my work with the CoP.

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
27. Serve youth transitioning to adult care?
28. Work with multidisciplinary Team members to transition youth?
29. Help prepare youth to transition 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
30. I feel confident in my ability to create transition plans with youth, families, and staff.
31. I do not feel confident addressing barriers to successful transition 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) = Disagree

(1) = Strongly Disagree

32. Our facility has formal transition policies and protocols.

33. At my facility, the transition process enhances the patient’s autonomy and increases their capacity for self-care and self-advocacy.

34. 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

35. I have a good understanding of the challenges of transitioning youth to adult clinics.

36. I am knowledgeable about strategies to help prepare youth for a successful transition.

37. I have integrated strategies to successfully transition youth into my practice.

For the Trauma-Informed Care Community of Practice participants ONLY:

We are interested in how the CoP will impact you personally. How confident are you that…	(5) =Very Confident	(4) = Confident	(3) = Undecided	(2) = Somewhat Confident	(1) = Not Confident
12. Your participation will expand your collaborative network?
13. Your participation will produce new knowledge in trauma-informed care to help you complete your work?
14. Your participation will change the way you conduct your work over the next year?
15. Your participation will increase your capacity to conduct your work?
16. Your participation in the CoP will increase opportunities to learn new information?
17. Your participation in the CoP will increase opportunities to learn new ways of doing your job?
18. Your participation in the CoP will increase opportunities to learn new evidence-based, evidence-informed, or emerging interventions/practices?
19. The CoP will meet its goals?
20. You will be able to develop productive collaborations within the CoP?

We are interested in how you think the CoP will impact the way you do your work. Please tell us about your expectations.	(5) = Greatly	(4) = Somewhat	(3) = Undecided	(2) = Very Little	(1) = Not At All
21. My knowledge of trauma-informed care will increase.
22. My knowledge of best practices will increase.
23. My learning expectations will be met.
24. My work is likely to change as a result of my experience with the CoP.
25. My networking experiences will increase.
26. I will take action on ideas that were generated as a result of my work with the CoP.

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
27. Work collaboratively with patients?
28. Support patients to talk about what they feel comfortable to disclose about their previous trauma?
29. Work with patients who have experienced trauma?
30. Provide trauma-informed care?

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
31. I feel confident acknowledging how hard it must be to talk about trauma.
32. I do not feel confident recognizing when someone is reexperiencing a traumatic event.

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) = Disagree		(1) = Strongly Disagree
33. Generally speaking, the staff at my facility has a solid understanding of trauma among persons with HIV.
34. Trauma-informed care is a primary emphasis in my facility.
35. Overall, the staff is supportive of efforts to enhance the use of trauma-informed care in my facility.
36. Overall, leadership is supportive of efforts to enhance the trauma-informed care provided in my facility.
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
37. It is not part of my role to listen to patients talk about their trauma.
38. I have a good understanding of what trauma-informed care means.
39. I can explain to patients what trauma is, including its effects.
40. I have a good understanding of how to take a sexual history using trauma-informed strategies.