4 Community of Practice Session Assessment

OMB Number: 0915-XXXX

Expiration Date: 12/31/2026

Public Burden Statement: To judge performance against goals, HRSA HAB will administer technical assistance evaluation surveys following TA and training, webinars, teleconferences, and meetings. Findings will drive quality improvement activities and reports. 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 0.08 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.

4. Community of Practice Session Assessment Instrument

Instructions:

To measure the effectiveness of the (insert date) Community of Practice (CoP) learning session, we invite you to complete this survey.

The survey will take about 5 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 improve the CoP learning sessions.

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

Please indicate the extent to which you agree with the following statements about today’s session.	(4) = Strongly Agree	(3) = Agree	(2) = Disagree	(1) = Strongly Disagree
9. My learning expectations were met.
10. I am satisfied with the quality of staff leading the session.
11. The content was engaging.
12. Facilitators were responsive to participants’ comments and questions.
13. The material presented was useful to me.
14. I expect that the session will benefit my patients.
15. I am satisfied with my experience.

Please rate the effectiveness of the following:	(4) = Very Effective	(3) = Effective	(2) = Somewhat Effective	(1) = Not at all Effective	(0) = Not Applicable
16. Facilitator-led presentations and PowerPoint slides
17. Videos
18. Practices
19. Report outs
20.Group discussions