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* 1. Name of Child Care Program?

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* 2. Name of person completing survey?

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* 3. Name of Technical Assistance Specialist who provided the services?

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* 4. Dates Technical Assistance was received? (Does not have to be exact. If only month and year are known, put "1" as the day.)

Start Date:
End Date:

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* 5. Number of visits received?

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* 6. Rate the TA Specialist/Service as follows: (5 is highest, Strongly Agree and 1 is the lowest, Strongly Disagree)

  5 4 3 2 1
The TA Specialist was knowledgeable
The TA Specialist was able to assist me in finding additional resources if needed (programs, people, materials)
The service was clearly explained to me
Overall rating of your experience

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* 7. What did you like most about participating in the Technical Assistance?

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* 8. What did you like the least about the Technical Assistance?

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* 9. Do you feel the quality of your classroom has improved as a result of the Technical Assistance?

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* 10. Would you recommend this service to another provider?

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* 11. Would you contact the TA Specialist for questions/TA in the future?

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* 12. Please list specific recommendations to improve the quality of service provided through the Technical Assistance?

T