0920-1050 Individual TA Feedback

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Individual TA Feedback
Please complete the survey below.
Thank you!

Form
OMB Control Number:
Exp Date: XX/20XX
Routine Technical Assistance (TA) Questionnaire
Thank you for participating in the technical assistance (TA) provided by the Core State Injury
Prevention Program (Core SIPP) team. We are committed to continuous quality improvement
(CQI) and improving our TA for recipients. To assist us with CQI, please take a few minutes to
fill out this brief questionnaire.
Questionnaire data will be shared with the Core SIPP team and used to improve future TA
delivery and outcomes. Participation in the survey is voluntary and all questions are optional.
We will not attach your name or the name of your organization to the questionnaire. If you
have any questions about this questionnaire, please send an email to coresipp2021@cdc.gov.
While answering this questionnaire, please think about any technical assistance (TA) you have
received over the past six months from CDC Core State Injury Prevention Program (Core SIPP)
Support Team. TA can be any assistance you have received, such as routine meetings with
Core SIPP staff, webinars, and/or discussions with injury topic area experts.
CDC estimates the average public reporting burden for this collection of information as 15
minutes per questionnaire, including the time for reviewing instructions, searching existing
data/information sources, gathering and maintaining the data/information needed, and
completing and reviewing the collection of information. 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).
Yes.

No.

I am not sure.

I have not worked on
Core SIPP for the past
six months.

1. Over the past six months,
have you received any TA from
the CDC Core SIPP Support
Team?

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2. Over the past six months, please indicate the
type(s) of technical assistance (TA) that you received
from Core SIPP. (Select all that apply).

Please describe: "Other"

3. Over the past six months, who did you receive TA
from at CDC? (Select all that apply).

Please describe: "Other"

4. Please indicate the type of support covered in your
TA with CDC over the past six months. (Select all that
apply).

Please describe: "Other"

5. Thinking back to what you expected or needed from
the TA you received, to what extent did the TA meet
your expectations?

Discussion with a Topic Area Expert
Emailed questions and answer(s)
Guidance developing resources/activities/documents
Monthly calls with Project Officers and/or
Evaluation Officers
Office hours
Resources such as written guidance, templates, or
technical packages
Site Visit
Trainings or webinars
I did not receive any TA over the past six months
Other:

__________________________________
Communications Team
Evaluation Officer
Policy Team
Project Officer
Topic Area Expert
Other

__________________________________
Adaptation- (Adapting programs for your
state/context)
Data/ Surveillance
Evaluation
Health Equity
NOFO Administration (For example, Budget Questions
and/or Workplan Development)
Partnerships
Policy Efforts
Program Implementation Support
Scientific writing
Strategies and approaches
Other

__________________________________
Not at all
A little
To some extent
Very much
Prefer not to answer
Not applicable

6. What, if anything, went well with the TA that you
received?

__________________________________

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

__________________________________

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

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9. Are there any specific topics that you would like
to see more TA around in the future?
10. What is your primary role in supporting Core SIPP?

Please specify: "Other"

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__________________________________
Communications
Core SIPP Project Manager/ Principal Investigator
Epidemiologist
Evaluator
Financial Staff
Program Staff
Other:

__________________________________

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