0920-1050 Participant Feedback Form for Peer Learning Communities

Att. 3. Participant Feedback Form for Peer Learning COMMUNITY

OMB Control No. 0920-1050

Exp. Date 06/30/2025

Public reporting burden of this collection of information is estimated to average 10 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).

To help us meet your training and technical assistance (TTA) needs, please take a few minutes to complete the following brief survey related to your participation in this peer learning community. Your participation is completely anonymous and voluntary. All survey questions are optional. You may choose to skip survey questions that you do not wish to answer or discontinue the survey at any point. 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).

Name of the Peer Learning Community/CoP: ___________________

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)

• Not sure

• Other: _____________________

1. Please describe your type of organization.

• State health department

• Local health department

• State domestic violence coalition

• Community based organization (sub-recipient)

• Other: ______________________

3. Briefly describe your primary role in your organization:

_________________________________________________________

3. How regularly do you attend meetings/calls held by this peer learning community? For example, if the peer learning community held 6 meetings in the last 6 months did you attend one meeting (rarely), 2-3 meetings (sometimes), 4 meetings (often), 5-6 meetings (almost always).

   1. Rarely (less than 25%)

   2. Sometimes (25-50%)

   3. Often (51-75%)

   4. Almost Always (more than 75%)

4. In what ways have you connected with other recipients through participation in this peer learning community? (select all that apply)

• Shared contact information or networking

• Exchanged resources, program documents, or other information

• Asked or answered questions

• Collaborated on a shared need or project

• Engaged in problem solving

• Other: _____________________________

3. Rate your level of agreement (strongly disagree, disagree, agree, or strongly agree) with the following statements about the quality of this peer learning community.

	Strongly disagree	Disagree	Agree	Strongly agree
I intend to use or apply information gained from this peer learning community in my professional work.				
I understood the information that was shared.				
I connected with other people doing this work.				
My cultural background, traditions, and identities were respected in this space.				
I would recommend participation in this peer learning engagement to others.				
I was inspired to do or think about something differently.				
The topic was in line with my organization’s needs and priorities.				

3. Overall, how satisfied were you with this peer learning community?

• Very dissatisfied

• Somewhat dissatisfied

• Somewhat satisfied

• Very satisfied

3. How do you intend to use what you’ve learned as part of this peer learning community?

___________________________________________________________________________

3. Are there any other types of peer learning communities you would like to see offered?

___________________________________________________________________________