9 Attachment I_CQI Practicum Check in Survey

OMB No: 0915-0212

Expiration date: 04/30/2024

CQI Practicum (Check in) Survey

Sent partway through CQI Practicum (2-3 months in)

Public Burden Statement: The purpose of this information collection request is to assess participant satisfaction with various training and TA activities offered through a contracted TA provider, the Education Development Center. 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. This data collection is voluntary. The OMB control number for this project is 0915-0212 and is valid until 04/30/2024. Public reporting burden for this collection of information is estimated to average .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.

1. Overall, how satisfied are you with CQI Practicum?

   1. Extremely satisfied

   2. Satisfied

   3. Dissatisfied

   4. Extremely dissatisfied

2. [If chosen “Dissatisfied” or “Extremely dissatisfied”] Please explain why you are dissatisfied with the CQI Practicum: [Open text]

3. How likely are you to use the information or ideas that you learned in the Practicum thus far in your work?

   1. Extremely likely

   2. Likely

   3. Unlikely

   4. Extremely unlikely

4. [If Unlikely/Extremely Unlikely] Please explain how we could improve the CQI Practicum information to be more relevant to your work. [Open text]

5. When have you been MOST engaged in the CQI Practicum? [Open text]

6. When have you been LEAST engaged in the CQI Practicum? [Open text]

7. We are particularly interested in whether our technical assistance is provided in a culturally appropriate manner. Please rate your agreement with the following statement: This CQI Practicum is provided in a culturally responsive manner (respectful of individual beliefs, language, perspectives, and needs)

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree