Attachment 8 Statement of Informed Consent

Form Approved OMB NO. 0930-0197 Exp. Date 12/31/2007 CENTER FOR SUBSTANCE ABUSE TREATMENT Attachment 2-5: Customer Satisfaction Survey—Training
Please enter the Personal ID code you used on the consent form here ________. Date of training, location (i.e., city, state), and topic will be pre-coded and entered in this area of the form.
Please check here ( ) if you have received this survey in error, (i.e., you did not attend the training listed above) and return the uncompleted survey in the enclosed postage-paid envelope. PLEASE BASE YOUR ANSWER ON HOW YOU FEEL ABOUT THE SESSION NOW.
	Very Satisfied	Satisfied	Neutral	Dissatisfied	Very Dissatisfied
1. How satisfied are you with the overall quality of this training?	1	2	3	4	5
2. How satisfied are you with the quality of the instruction?	1	2	3	4	5
3. How satisfied are you with the quality of the training materials?	1	2	3	4	5
4. Overall, how satisfied are you with your training experience?	1	2	3	4	5
PLEASE INDICATE YOUR AGREEMENT WITH THESE STATEMENTS ABOUT THE TRAINING.	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
5. The training class was well organized.	1	2	3	4	5
6. The material presented in this class will be useful to me in dealing with substance abuse.	1	2	3	4	5
7. The instructor was knowledgeable about the subject matter.	1	2	3	4	5
8. The instructor was well prepared for the course.	1	2	3	4	5
The instructor was receptive to participant comments and questions.	1	2	3	4	5
10. I am currently effective when working in this topic area.	1	2	3	4	5
11. The training enhanced my skills in this topic area.	1	2	3	4	5
12. The training was relevant to my career.	1	2	3	4	5
13. I expect to use the information gained from this training.	1	2	3	4	5
14. I expect this training to benefit my clients.	1	2	3	4	5
15. This training was relevant to substance abuse treatment.	1	2	3	4	5
16. I would recommend this training to a colleague.	1	2	3	4	5
________________________________________ Public reporting burden for this collection of information is estimated to average 10 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, Room 7-1044, 1 Choke Cherry Road, 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 0930-0197.

		Very Useful	Useful	Neutral	Useless	Not Applicable
	17. How useful was the information you received from the instructor?	1	2	3	4	5
	Please indicate which title best describes your job: ___Medical Director ___Clinical Administrator/Manager ___Federal Government Official ___Physician ___Clinical Supervisor ___State Government Official ___Nurse ___Psychologist ___County Government Official ___Physician's Assistant ___Counselor ___Researcher ___Pharmacist ___Social Worker ___Other (please specify)____________ ___Other (please describe) ___Manager/Director
	Please indicate which best describes your agency or affiliation: ___Federal Government ___Substance Abuse Treatment Program ___State Government ___University or other higher education institution ___County Government ___Other (please describe)_________________________________ ___Local Government
	20. What is your gender? 1.____Male 2.____Female 21. Are you Hispanic or Latino? 1.____Yes 2.____No What is your race (Mark all that apply)? ____Black or African American ____Alaska Native ____Asian ____American Indian ____White ____Native Hawaiian or Other Pacific Islander
	What about the training was most useful in supporting your work responsibilities?
	How can CSAT improve its training?
	Thank you for completing our survey. Return your survey to the Survey Administrator for you Session.

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