1Supporting Statement - National Cross-Site Assessment of ATTC 9-25-06.rtf

Form Approved

OMB No. 0930-0216

Expiration Date XX/XX/XXXX

Attachment 1-2: ATTC Pre-Event Form─Meetings and Technical Assistance

___________________________________________________________________________________________

Personal Code:

___ First Letter in Mother’s First Name ___ First Letter in Mother’s Maiden Name

___ First digit in Social Security Number ___ Last digit in Social Security Number

________________________________________________________________________________ __________

Birth Year: 19____ Previous ATTC Participant: ___ Yes ___ No

Gender: ____ Male ____ Female

Are you Hispanic or Latino? ____ Yes ____ No

Race (Check all that apply):

___ Black or African American ___ Asian ____ American Indian

___ Native Hawaiian/Other Pacific Islander ___ Alaska Native ____ White

Years of Experience in Addictions:

___ I have worked in the addiction field for _______ years.

___ I am not employed in the addiction field.

Certification Status in Addictions Field:

_____ Not certified or licensed in addictions _____ Currently certified or licensed

_____ Previously certified or licensed, not now _____ Intern

Highest Degree Status:

_____ No high school diploma or equivalent _____ Bachelor’s degree

_____ High school diploma or equivalent _____ Master’s degree

_____ Some college, but no degree _____ Doctoral degree or equivalent

_____ Associate’s degree _____ Other, specify: _______________________

Discipline/Profession (Please check all that apply)

___ Addictions Counselor ___ Social Work/Human Services ___ Administration

___ Other Counseling ___ Physician Assistant ___ None, unemployed

___ Education ___ Medicine – Primary Care ___ None, student

___ Vocational Rehabilitation ___ Medicine – Psychiatry ___ Other, specify: _____

___ Criminal Justice ___ Medicine – Other _____________________

___ Psychology ___ Nurse/Nurse Practitioner

Primary Work Setting (please check all that apply):

___ Criminal Justice ___ Private practice ___ Student

___ Outpatient ___ Outreach ___ Other, specify: _____

___ Inpatient facility ___ Substance Abuse Treatment agency ______________________

___ Educational institution ___ Community Mental Health center

___ Residential facility ___ Health/community health agency

Primary Job Responsibility: (please check all that apply)

_____ Line staff (counselors, K-12 teachers, corrections officers, etc.) _____ Administration

_____ Supervision of case managers and/or counselors _____ Training/Education

_____ Other (specify: ________________)

Current Training Goals: (check all that apply)

_____ Professional development (no CEUs) _____ Continuing education (CEUs awarded)

_____ Addictions certification (state or other) _____ Academic credit toward a BA

_____ Academic credit toward a Master’s _____ Academic credit toward licensure

_____ Other (specify): _______________ _____ No current goals

_______________________

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information to the SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, MD 20857. 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. The control number for this project is 0930-0216.