State and Tribal Technical Assistance and Resources Training and Technical Assistance Feedback Surveys

OMB #: 0970-0401

Expiration Date: XX/XX/2027

Notes for Administration of Survey: The below questions are to gather feedback from participants in OFA’s STAR training and technical assistance (TTA) activities, at the conclusion of the TTA activity. The proposed questions gather feedback about the knowledge and skills that participants have at the end of the event and their experience attending TTA activities. Responses to the proposed feedback questions will be gathered through two means: (1) web-based surveys or (2) hard copy-based surveys at the conclusion of an event. No more than 16 questions from the below set will be selected for each TTA activity.

[TTA Activity Title]

Feedback Post-Survey

Intro Text for Respondents: Your feedback is essential to helping us improve the technical assistance we offer. Thank you for taking the time to share your thoughts with us. We guarantee the privacy of the information you provide. Answers to the questions below will only be reported after combining all responses. The results will not identify you as an individual.

First, please rate the knowledge and skills you have now at the end of this [TTA activity].

Select one per row

	No knowledge	Limited knowledge	Moderate knowledge	Considerable knowledge	Extensive knowledge
1. How would you rate your knowledge about [learning objective topic 1]?	1 	2 	3 	4 	5 
2. How would you rate your knowledge about [learning objective topic 2]?	1 	2 	3 	4 	5 
3. How would you rate your knowledge about [learning objective topic 3]?	1 	2 	3 	4 	5 
4. How would you rate your knowledge about [learning objective topic 4]?	1 	2 	3 	4 	5 

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN:

The purpose of this information collection is to gather feedback from participants in Office of Family Assistance technical assistance activities about the quality of the technical assistance they receive. Public reporting burden for this collection of information is estimated to average 7 minutes per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0401 and the expiration date is XX/XX/2027. If you have any comments on this collection of information, please contact Lizeth Hester at Lizeth.hester@acf.hhs.gov.

5. How would you rate your current skills related to [learning objective skill 1]?

Select one only

1  No ability

2  Limited ability

3  Moderate ability

4  Considerable ability

5  Extensive ability

6. What are the last four digits of your phone number?
We will only use this information to connect your responses to questions 1-5 with your responses on the pre-survey. This helps us understand changes in participants’ knowledge and skills.

Last four digits of phone number: ___ ___ ___ ___

For the next questions, please tell us how much you agree or disagree with each statement.

Select one per row

	Strongly disagree	Disagree	Agree	Strongly agree	Not applicable
7. Based on my experience, this [TTA activity] [experience objective 1].	1 	2 	3 	4 	NA 
8. Based on my experience, this [TTA activity] [experience objective 2].	1 	2 	3 	4 	NA 
9. Based on my experience, this [TTA activity] [experience objective 3].	1 	2 	3 	4 	NA 
10. Based on my experience, this [TTA activity] [experience objective 4].	1 	2 	3 	4 	NA 

11. What was the highlight of your experience at this event?

We hope that when you leave the [TTA activity], you are ready to [vision for change objective]. The next questions ask about your readiness to take action.

Select one per row

	Strongly disagree	Disagree	Agree	Strongly agree
12. I have the knowledge, skills, and abilities I need to use what I gained from this [TTA activity] to [vision for change objective].	1 	2 	3 	4 
13. I have the external resources or support I need to use what I gained from this [TTA activity] to [vision for change objective].	1 	2 	3 	4 
14. I feel motivated to use what I gained from this [TTA activity] to [vision for change objective].	1 	2 	3 	4 

15. Tell us about how you might take action, including what you might need to help you to [vision for change objective]. If you do not plan to take action, describe what’s holding you back.

The next questions ask about your satisfaction. Please tell us how much you agree or disagree with each statement.

Select one per row

	Strongly disagree	Disagree	Agree	Strongly agree
16. The overall logistics of the [TTA activity] were organized.	1 	2 	3 	4 
17. This [TTA activity] was directly relevant to our program’s needs and aspirations.	1 	2 	3 	4 
18. I am satisfied with the overall quality of this [TTA activity].	1 	2 	3 	4 

19. Please share your feedback about this [TTA activity.] Tell us what made it worthwhile and what we can do to improve.

Thank you!

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