0920-1050 Recipient Feedback Form for Individual TA

Att. 4. Recipient Feedback ForM for Individual TA

OMB Control No. 0920-1050

Exp. Date 06/30/2025

Public reporting burden of this collection of information is estimated to average 15 minutes per respondent. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia, 30333; ATTN: PRA (0920-1050).

Thank you for participating in technical assistance (TA) provided by CDC’s Violence Prevention Technical Assistance Center (VPTAC). VPTAC serves as a central source of TA for all health departments, domestic violence coalitions, and other organizations receiving funding from the Prevention Practice and Translation Branch (PPTB) in the Division of Violence Prevention at the Centers for Disease Control and Prevention (CDC).

VPTAC is committed to continuous quality improvement. To assist us with that, please take a few minutes to complete this brief survey. In answering, please think about the technical assistance support that your organization received from VPTAC specific to the technical assistance request that you submitted. When you answer questions, please respond on behalf of your team; VPTAC is interested in your site’s collective feedback. We will not attach your name or the name of your organization to the survey. Survey data will be shared with the TA provider and the VPTAC evaluation team and used to improve future TA delivery and outcomes. Participation in the survey is voluntary and all questions are optional. If you have any questions about VPTAC or this survey, please send an email to either your project officer or Dr. Lindsey Barranco (yzi9@cdc.gov).

1. Please indicate whether you are involved in any of the following CDC-funded programs. (Check all that apply.)

• Rape Prevention and Education (RPE)

• Domestic Violence Prevention Enhancements and Leadership Through Alliances (DELTA) AHEAD

• Essentials for Childhood: Implementation of Strategies and Approaches for Child Abuse and Neglect Prevention

• Preventing Violence Affecting Young Lives (PREVAYL)

• Preventing Adverse Childhood Experiences: Data to Action (PACE:D2A)

• Other: _____________________

2. Please describe your type of organization.

• State health department

• Local health department

• State domestic violence coalition

• Community based organization (sub-recipient)

• Other: ______________________

3. What organization(s) did you receive TA from in response to this request? (Check all that apply)

1. CDC staff

2. AIR

3. NSVRC

4. NRCDV

5. Other: _____________

3. Please indicate the type(s) of individual TA that you received from VPTAC (select all that apply).

   1. Conference call(s)/Virtual Meetings

   2. Email(s)

   3. Received resources

   4. Site visit

   5. Specific training related to TA request

   6. Assistance developing resources/documents

   7. Other __________________________

4. Please indicate the topic(s) that you covered in your engagements with VPTAC (select all that apply).

• Planning

• Partnerships

• Policy efforts

• Strategies and approaches

• Adaptation

• Implementation

• Evaluation or data

• Health Equity

• Other __________________________

3. Thinking back to what you wanted or expected to learn from this TA to what extent did the TA meet your expectations?

1. Not at all

2. A little

3. To some extent

4. Very much

3. Please further describe how this TA met or did not meet your expectations.

___________________________________________________________________________

3. Please indicate the extent to which you agree or disagree with the following statement: I have used or plan to use information gained from this TA in my professional work.

1. Strongly disagree

2. Disagree

3. Agree

4. Strongly agree

3. If applicable, please share examples of how you have used or plan to use information gained from the TA in your professional work.

___________________________________________________________________________

3. What, if anything, would have improved the TA you received?

__________________________________________________________________________________

3. Are there any specific topics that you would like to see more TA around in the future?

__________________________________________________________________________