0920-1050 Recipient Follow Up Form for Individual TA

Att. 5. Recipient Follow-up 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 TA that you or people in your organization received from VPTAC approximately six months ago in relation to the TA 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: _____________________

1. Please describe your type of organization.

• State health department

• Local health department

• State domestic violence coalition

• 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. Site visit

4. Received resources

5. Specific training related to TA request

6. Assistance developing resources/documents

7. Other __________________________

4. 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: _____________

5. Please indicate the topic(s) that you covered while receiving technical assistance related to this request? (select all that apply).

• Planning

• Partnerships

• Policy efforts

• Strategies and approaches

• Adaptation

• Implementation

• Evaluation or data

• Health Equity

• Other __________________________

6. Please indicate the extent to which you agree or disagree with the following statement: We have applied or used the information or skills gained through TA to improve our work.

1. Strongly disagree

2. Disagree

3. Agree

4. Strongly agree

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

___________________________________________________________________________

8. Please indicate the extent to which you agree or disagree with the following statement: The TA received increased my organization’s capacity to plan, implement, or evaluate our violence prevention initiative?

1. Strongly disagree

2. Disagree

3. Agree

4. Strongly agree

9. Did you share the information or resources you gained from this TA with others?

1. Yes, with partners and subrecipients

2. Yes, with subrecipients

3. Yes, with partners

4. No

10. Please describe if and how your partners or subrecipients used the information or resources you shared with them.

___________________________________________________________________________

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

___________________________________________________________________________