Form Forms Attachments A-J

Voluntary Customer Satisfaction Surveys to Implement Executive Order 12862 in the Substance Abuse and Mental Health Services Administration (SAMHSA)

ATTACHMENT A-J

Fetal Alcohol Spectrum Disorder (FASD) Center for Excellence

OMB: 0930-0197

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0930-0197 can be found here:

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ATTACHMENT A

FASD EVENT PRE-test form (tRAININGS)

SAMHSA Fetal Alcohol Spectrum Disorders Center for Excellence

FASD Event Pre-Test Form

The purpose of this form is to gather information to adequately assess the effectiveness of our services. The form is completely anonymous. Please do NOT put your name anywhere on this form. Results will be used to inform similar future events. It is important to obtain information from all participants to maintain quality of service; however, your participation is voluntary.

Name of Event:

Location of Event: Date of Event:

Event Code:

SAMHSA FASD Center for Excellence will be using the unique identification code below to link your answers to information about today’s training, but will not be able to identify your name or any other information about you. In order to match the pre-training, post-training, and follow-up evaluation forms, we would like for you to provide the following information. The information will allow matching of the surveys without identifying who you are.

First letter in mother’s first name: ___ First letter in mother’s maiden name: ___

First letter in the city of your birth: ___ First letter in the state of your birth: ___

First letter in your first name: ___

Feel free to use the back of the page if you need more room for written comments.

1. What is your gender?  Male  Female

2. Are you Hispanic or Latino?  Yes  No

3. How would you describe your racial background? (Check all that apply.)

 American Indian  Alaska Native  Asian  Black or African American

 Native Hawaiian or Other Pacific Islander  White

4. What is the highest level of education you have completed? (Choose highest level only.)

 Less than high school  High school or equivalent  Associate’s  Bachelor’s

 Master’s  Doctorate  Other post-doctorate

5. Please indicate what field you are in. We have left room next to each choice for you to briefly describe that experience. (Check all that apply.)

 Person living with an FASD

 Direct Caregiver (e.g., parent, grandparent)

 Adult Justice

 Advocacy

 Child Welfare

 Education

 Government

 Housing

 Juvenile Justice

 Media

 Medical/Health Services

 Mental Health Services

 Public Health

 Research

 Retail

 Social Services

 Student

 Substance Abuse Treatment

 Vocational Services

 Other

6. Please indicate whether each of the following statements is false or true. (Check one box on each line.)

	True	False
FASD is a diagnosis used for individuals who were exposed prenatally to alcohol	□	□	⁪	⁪
The majority of individuals with an FASD have mental retardation	□	□	⁪	⁪
Fetal alcohol syndrome is a childhood disorder	□	□	⁪	⁪
It is important to have a lot of stimulation in a classroom for a child with an FASD	□	□	⁪	⁪
In order to get a diagnosis of ARND, a person must have some of the facial features of FAS	□	□	⁪	⁪
The corpus callosum is often damaged by prenatal alcohol exposure	□	□	⁪	⁪
There is no confirmed safe amount of alcohol to use during pregnancy	□	□	⁪	⁪
Verbal receptive language is less impaired than verbal expressive language in individuals with an FASD	□	□	⁪	⁪
If a father drinks heavily before conception but the mother doesn’t drink during pregnancy, a baby can still be born with FAS	□	□	⁪	⁪
Damage to the brain due to prenatal alcohol exposure can cause some of the behaviors seen in FASD	□	□	⁪	⁪

Thank you!

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 OMB control number for this project is 0930-0197. Public reporting burden for this collection of information is estimated to average 5 minutes per client per year, 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, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

ATTACHMENT B

FASD EVENT POST-TEST FORM (TRAININGS)

S AMHSA Fetal Alcohol Spectrum Disorders Center for Excellence

FASD Event Post-Test Form

Name of Event:

Location of Event: Date of Event:

Event Code:

First letter in mother’s first name: ___ First letter in mother’s maiden name: ___

First letter in the city of your birth: ___ First letter in the state of your birth: ___

First letter in your first name: ___

Feel free to use the back of the page if you need more room for written comments.

1. Please indicate whether each of the following statements is false or true. (Check one box on each line.)

	True	False
It is important to have a lot of stimulation in a classroom for a child with an FASD	□	□	⁪	⁪
Verbal receptive language is less impaired than verbal expressive language in individuals with an FASD	□	□	⁪	⁪
There is no confirmed safe amount of alcohol to use during pregnancy	□	□	⁪	⁪
The corpus callosum is often damaged by prenatal alcohol exposure	□	□	⁪	⁪
If a father drinks heavily before conception but the mother doesn’t drink during pregnancy, a baby can still be born with FAS	□	□	⁪	⁪
The majority of individuals with an FASD have mental retardation	□	□	⁪	⁪
In order to get a diagnosis of ARND, a person must have some of the facial features of FAS	□	□	⁪	⁪
Fetal alcohol syndrome is a childhood disorder	□	□	⁪	⁪
Damage to the brain due to prenatal exposure can cause some of the behaviors seen in FASD	□	□	⁪	⁪
FASD is a diagnosis used for individuals who were exposed prenatally to alcohol	□	□	⁪	⁪

Thank you!

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 OMB control number for this project is 0930-0197. Public reporting burden for this collection of information is estimated to average 4 minutes per client per year, 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, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

ATTACHMENT C

FASD EVENT fEEDBACK FORM (tRAININGS)

SAMHSA Fetal Alcohol Spectrum Disorders Center for Excellence

F ASD Event Feedback Form

The purpose of this form is to obtain your feedback on this event. The form is completely anonymous. Please do NOT put your name anywhere on this form. Results will be used to inform similar future events. It is important to obtain information from all participants to maintain quality of service; however, your participation is voluntary.

Name of Event:

Location of Event: Date of Event:

Event Code:

1.1

First letter in mother’s first name: ___ First letter in mother’s maiden name: ___

First letter in the city of your birth: ___ First letter in the state of your birth: ___

First letter in your first name: ___

Feel free to use the back of the page if you need more room for written comments.

1. Please rate your satisfaction with each of the following aspects of today's training. (Check one box on each line.)

Very Somewhat Somewhat Very

Dissatisfied Dissatisfied Satisfied Satisfied

a . Quality of the information you received

Comments:

b . Relevance of the information to your work

Comments:

c . Organization of the training

Comments:

d . Opportunity for questions/discussion

Comments:

e . Handouts or materials

Comments:

2. Please use the following scale to rate [SPEAKER A]. (Check one box on each line.) ⁪

Poor Fair Good Excellent NA

a . Overall quality of speaker

b . Knowledge of subject matter

c . Enthusiasm for subject

d . Use of examples/clarifying techniques

e . Willingness/capacity to respond to questions

f . Sensitivity of speaker to participants

3. Please use the following scale to rate [SPEAKER B]. (Check one box on each line.) ⁪ ⁪ ⁪ ⁪

Poor Fair Good Excellent NA

a . Overall quality of speaker

b . Knowledge of subject matter

c . Enthusiasm for subject

d . Use of examples/clarifying techniques

e . Willingness/capacity to respond to questions

f . Sensitivity of speaker to participants

4. Please use the following scale to rate [SPEAKER C]. (Check one box on each line.) ⁪ ⁪ ⁪ ⁪

Poor Fair Good Excellent NA

a . Overall quality of speaker

b . Knowledge of subject matter

c . Enthusiasm for subject

d . Use of examples/clarifying techniques

e . Willingness/capacity to respond to questions

f . Sensitivity of speaker to participants

5. How successful was this training in meeting the following objectives? (Check one box on each line.)

Not Very Somewhat Mostly Very

Successful Successful Successful Successful

a . Define the term FASD

b . Identify typical difficulties many people with an FASD have

c. Describe person first language

d . Discuss methods to prevent FASD

6a. What were the most helpful features of today's training?

6b. What were the least helpful features of today's training?

7. In what ways could this training be improved?

8. How much new information or ideas did you receive in the training? (Check one.)

 No New Information/Ideas  A Little New Information/Ideas

 Some New Information/Ideas  A Lot of New Information/Ideas

9. How much did the information you received today reinforce what you thought or knew?

 Not At All

 A Little

 Some

 A Lot

10. How likely are you to use the information or ideas that you received in the training? (Check one.)

 Not At All Likely

 Not Very Likely

 Somewhat Likely

 Very Likely

11. Overall, how satisfied are you with today's training? (Check one.)

 Very Dissatisfied

 Somewhat Dissatisfied

 Somewhat Satisfied

 Very Satisfied

12. What other topics related to FASD would be of most interest to you?

13. Please write in any additional comments or suggestions that you may have.

Thank you!

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 OMB control number for this project is 0930-0197. Public reporting burden for this collection of information is estimated to average 10 minutes per client per year, 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, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

ATTACHMENT D

FASD TRAINING FEEDBACK SURVEY (TRAININGS)

SAMHSA Fetal Alcohol Spectrum Disorders Center for Excellence

F ASD Training Feedback Survey

Name of Event:

Location of Event: Date of Event:

Event Code:

SAMHSA FASD Center for Excellence will be using the unique identification code below to link your answers to information about the event, but will not be able to identify your name or any other information about you. In order to match the pre-training, post-training, and follow-up evaluation forms, we would like for you to provide the following information. The information will allow matching of the surveys without identifying who you are.

First letter in mother’s first name: ___ First letter in mother’s maiden name: ___

First letter in the city of your birth: ___ First letter in the state of your birth: ___

First letter in your first name: ___

Thank you for agreeing to provide us with feedback on the recent FASD event in which you participated.

1. How useful have the information/ideas/skills that you received in the event been to you?

 Not at All Useful  Not Very Useful  Somewhat Useful  Very Useful

Comments:

2. To what extent have the information/ideas/skills covered in the training been fully implemented?

 Fully  Partially  Not yet begun

If “fully” or “partially,” could you provide us with an example of how you have been able to do so?

If “not yet begun,” do you intend to implement the information/ideas/skills covered in the training in the future?

Yes  No

Have there been any barriers to implementing the information/ideas/skills that you received in the training?

If “yes,” please describe.

Yes  No

3. To what extent have the information/ideas/skills that you received improved your capacity to provide effective prevention

services?

 Not at All  Not Very Much  Somewhat  A Great Deal  Not Applicable

4. To what extent have the information/ideas/skills that you received improved your capacity to provide effective treatment

services?

 Not at All  Not Very Much  Somewhat  A Great Deal  Not Applicable

5. To what extent have the information/ideas/skills that you received improved your day-to-day interactions with people with

an FASD and their families?

 Not at All  Not Very Much  Somewhat  A Great Deal  Not Applicable

6. Feel free to add any additional information on how such service could be improved in the future.

Thank you!

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 OMB control number for this project is 0930-0197. Public reporting burden for this collection of information is estimated to average 8 minutes per client per year, 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, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

S AMHSA Fetal Alcohol Spectrum Disorders Center for Excellence

FASD Event Follow-up Protocol

NOTE: This process will be automated as part of the FASD Event Database. The OMB control number and burden statement will appear on the first web page of the form.

E-MAIL INVITATION:

At the SAMHSA FASD Center for Excellence, we are continually working to improve our services. To that end, we would like your feedback on a recent FASD event in which you participated – the <name and description of event> held in <location of event>.

To provide your valuable feedback, simply click on the link below while you are connected to the Internet and a new feedback browser window should open. If the link is not highlighted, or if a new window does not open when you click on the link, simply copy and paste the address into the location bar of your browser’s window.

Click on this link to begin the feedback survey: <link to feedback survey>

If you would rather provide your feedback through an interview instead of completing the brief on-line survey, click on the link below to arrange an interview.

Click on this link if you would rather provide your feedback through an interview:

<link to interview page>

If you would prefer not to participate, click on the link below.

Click on this link if you would prefer not to participate: <link to opt-out page>

Thank you in advance for your cooperation. If you have any questions about this process, you can contact <name of contact person> at the SAMHSA FASD Center for Excellence

INTERVIEW PAGE:

If you would rather provide your feedback through an interview instead of completing the brief on-line survey, please call the Center at 1-866-786-7327 (1-866-STOPFAS) and state that you are responding to the event follow-up.

If you would prefer not to participate, click on the link below.

Click on this link if you would prefer not to participate: <link to opt-out page>

Thank you in advance for your cooperation. If you have any questions about this process, you can contact <name of contact person> at the Center at 1-866-786-7327.

OPT-OUT PAGE:

If you would prefer not to provide feedback on the FASD event, please check the box below and hit the submit button. Your information will be entered into our system and you will not receive further contacts about this service.

⁪I would prefer not to provide feedback at this time

REMINDER E-MAIL MESSAGE TO NON-RESPONDENTS (Trainings)

Dear Colleague,

Our records indicate that we have not yet received your feedback about a recent FASD Center for Excellence event, <name of event>, in which you participated. It is important for us to obtain information from all event participants in order to ensure that future FASD services meet your needs.

Providing your feedback is easy. Simply click on the link below while you are connected to the Internet and a new browser window should open. If the link is not highlighted, or if a new window does not open when you click on the link, simply copy and paste the address into the location bar of your browser’s window.

Click on this link to begin the feedback survey: <link to feedback survey>

If you would rather provide your feedback through an interview instead of completing the brief on-line survey, please call the Center at 1-866-786-7327 (1-866-STOPFAS) and state that you are responding to the event follow-up.

If you would prefer not to participate, click on the link below.

Click on this link if you would prefer not to participate: <link to opt-out page>

Thank you in advance for your cooperation. If you have any questions about this process, you can contact <name of contact person> at the FASD Center for Excellence at 1-866-786-7327.

ATTACHMENT E

PRE-MEETING FORM (INFORMATIONAL MEETINGS FOR FIELD TRAINERS)

SAMHSA Fetal Alcohol Spectrum Disorders Center for Excellence

P re-Meeting Form (Field Trainers)

Name of Meeting:

Location of Meeting: Date of Meeting:

Meeting Code:

SAMHSA FASD Center for Excellence will be using the unique identification code below to link your answers to information about today’s meeting, but will not be able to identify your name or any other information about you. In order to match the pre-, post- and follow-up evaluation forms, we would like for you to provide the following information. The information will allow matching of the surveys without identifying who you are.

First letter in mother’s first name: ___ First letter in mother’s maiden name: ___

First letter in the city of your birth: ___ First letter in the state of your birth: ___

First letter in your first name: ___

1. What is your gender?  Male  Female

2. Are you Hispanic or Latino?  Yes  No

3. How would you describe your racial background? (Check all that apply)

 American Indian  Alaska Native  Asian  Black or African American

 Native Hawaiian or Other Pacific Islander  White

4. What is the highest level of education you have completed? (Choose highest level only.)

 Less than high school  High school or equivalent  Associate’s  Bachelor’s

 Master’s  Doctorate  Other post-doctorate

How long have you worked in a field in which you encounter FASD?

Under 1 year

1–5 years

6–10 years

11–15 years

Over 15 years

Not Applicable

How long have you been providing training in FASD?

Under 1 year

1–5 years

6–10 years

11–15 years

Over 15 years

Not Applicable

Estimate the number of people who received training from you in the previous 12 months. _____

Please indicate the primary setting in which you deliver training. (Please check one box.)

Adult Justice	Private Practice
Educational Institution	Research Organization
Inpatient Facility (Acute) Juvenile Justice	Residential Facility (Long-term) Social Service Agency
Outpatient	State/Local Government
Outreach	Other: specify

Do you primarily provide training in Tribal settings?

Yes Please specify: ________________________________________________________________________________
No

Have you ever provided clinical services in a professional capacity to someone with an FASD?

Yes Please specify: ________________________________________________________________________________
No

Describe the extent to which you agree or disagree with the following statements. (Check one box on each line.)

Strongly Somewhat Somewhat Strongly NA

Disagree Disagree Agree Agree

I feel confident that the information in my

presentation is current (i.e., post-2007).

I feel confident about my presentation skills.

U pdated training on FASD is a valuable

investment of my time.

T he content of this session will apply to

most of my training activities.

Comments:

Please answer the questions below to the best of your ability.

A. What are the three components necessary for diagnosing FAS?

low set ears, a smooth philtrum, and a thin upper lip
flat midface, smooth philtrum, and a thin upper lip
smooth philtrum, short palpebral fissures, and a thin upper lip
short palpebral fissures, smooth philtrum, and a small jaw

B. Which of the following is NOT an appropriate strategy for helping a child with an FASD succeed in a school setting?

Consistency in activities and times
Utilizing a level or point system
Limiting or eliminating homework that needs to be done at home
Reducing stimuli in the classroom

C. Misdiagnosis of an FASD can result in:

Inappropriate interventions being put in place
Expectations of the ability to follow multiple directions
View that behavior is purposeful
All of the above

D. Which of the following tends to be the most impaired in individuals with an FASD?

Immediate or working memory
Long term memory
Retrospective memory
All memory

E. Individuals with an FASD learn best by:

a. Being told what to do

b. Modeling the behavior of those around them

c. Being given a list of written directions

d. Using something they like to do as a reward for doing what they need

Thank you!

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 OMB control number for this project is 0930-0197. Public reporting burden for this collection of information is estimated to average 7 minutes per client per year, 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, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

ATTACHMENT F

POST-MEETING EVALUATION FORM

(INFORMATIONAL MEETINGS FOR FIELD TRAINERS)

S AMHSA Fetal Alcohol Spectrum Disorders Center for Excellence

Post-Meeting Evaluation Form (Field Trainers)

Name of Meeting:

Location of Meeting: Date of Meeting:

Meeting Code:

SAMHSA FASD Center for Excellence will be using the unique identification code below to link your answers to information about today’s meeting, but will not be able to identify your name or any other information about you. In order to match the pre-, and post- evaluation forms, we would like for you to provide the following information. The information will allow matching of the surveys without identifying who you are.

First letter in mother’s first name: ___ First letter in mother’s maiden name: ___

First letter in the city of your birth: ___ First letter in the state of your birth: ___

First letter in your first name: ___

Please use the following scale to evaluate today’s meeting. (Check one box on each line.)

Poor Fair Good Very Good Excellent

Overall, please rate the….

Q uality of the information you received

Comments:

R elevance of the information to your work

Comments:

O rganization of the meeting

Comments:

S ensitivity of the trainer(s) to the participants

Comments:

O pportunity for questions/discussion

Comments:

H andouts or materials

Comments:

O verall quality of the meeting

Comments:

2. Please use the following scale to rate [SPEAKER A]. (Check one box on each line.) ⁪ ⁪ ⁪ ⁪

Poor Fair Good Excellent NA

a . Overall quality of speaker

b. Knowledge of subject matter

c. Enthusiasm for subject

d. Use of examples/clarifying techniques

e. Willingness/capacity to respond to questions

f. Sensitivity of speaker to participants

3. Please use the following scale to rate [SPEAKER B]. (Check one box on each line.) ⁪⁪ ⁪ ⁪

Poor Fair Good Excellent NA

a . Overall quality of speaker

b. Knowledge of subject matter

c. Enthusiasm for subject

d. Use of examples/clarifying techniques

e. Willingness/capacity to respond to questions

f. Sensitivity of speaker to participants

4. Please use the following scale to rate [SPEAKER C]. (Check one box on each line.) ⁪ ⁪ ⁪ ⁪

Poor Fair Good Excellent NA

a . Overall quality of speaker

b. Knowledge of subject matter

c. Enthusiasm for subject

d. Use of examples/clarifying techniques

e. Willingness/capacity to respond to questions

f. Sensitivity of speaker to participants

5. Describe the extent to which you agree or disagree with the following statements. (Check one box on each line.)

Strongly Somewhat Somewhat Strongly NA

Disagree Disagree Agree Agree

T his meeting met my needs for training in FASD.

T his meeting provided me with adequate new

knowledge of FASD.

T his meeting enhanced my presentation skills.

T he content of this session applied to

most of my training activities.

I plan on sharing the information in this

meeting with a colleague.

T his meeting was a beneficial use of my time.

I plan to use information from this meeting

in my training activities.

6. Please answer the questions below to the best of your ability.

A. What are the three components necessary for diagnosing FAS?

a. low set ears, a smooth philtrum, and a thin upper lip

b. flat midface, smooth philtrum, and a thin upper lip

c. smooth philtrum, short palpebral fissures, and a thin upper lip

d. short palpebral fissures, smooth philtrum, and a small jaw

B. Which of the following is NOT an appropriate strategy for helping a child with an FASD succeed in a school setting?

a. Consistency in activities and times

b. Utilizing a level or point system

c. Limiting or eliminating homework that needs to be done at home

d. Reducing stimuli in the classroom

C. Misdiagnosis of an FASD can result in:

Inappropriate interventions being put in place
Expectations of the ability to follow multiple directions
View that behavior is purposeful
All of the above

D. Which of the following tends to be the most impaired in individuals with an FASD?

Immediate or working memory
Long term memory
Retrospective memory
All memory

E. Individuals with an FASD learn best by:

a. Being told what to do

b. Modeling the behavior of those around them

c. Being given a list of written directions

d. Using something they like to do as a reward for doing what they need

7. What are potential barriers to applying the information/skills presented in this meeting to your trainings?

8. What were the most helpful features of the meeting?

9. What were the least helpful features of the meeting?

10. In what ways could this meeting be improved?

11. Overall, how satisfied are you with this meeting? (Check one.)

 Very Dissatisfied

 Somewhat Dissatisfied

 Somewhat Satisfied

 Very Satisfied

Thank you!

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 OMB control number for this project is 0930-0197. Public reporting burden for this collection of information is estimated to average 10 minutes per client per year, 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, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

ATTACHMENT G

FASD MEETING FOLLOW-UP FEEDBACK SURVEY

(INFORMATIONAL MEETINGS FOR FIELD TRAINERS)

SAMHSA Fetal Alcohol Spectrum Disorders Center for Excellence

F ASD Meeting Follow-up Feedback Survey

Name of Meeting:

Location of Meeting: Date of Meeting:

Meeting Code:

SAMHSA FASD Center for Excellence will be using the unique identification code below to link your answers to information about the meeting, but will not be able to identify your name or any other information about you. In order to match the evaluation forms, we would like for you to provide the following information. The information will allow matching of the surveys without identifying who you are.

First letter in mother’s first name: ___ First letter in mother’s maiden name: ___

First letter in the city of your birth: ___ First letter in the state of your birth: ___

First letter in your first name: ___

Thank you for agreeing to provide us with feedback on the recent FASD meeting in which you participated.

1. How useful has the information, ideas, or skills that you received in the meeting been to you?

 Not at All Useful  Not Very Useful  Somewhat Useful  Very Useful

Comments:

2. To what extent have the information/ideas/skills covered in the meeting been implemented in your trainings?

 Fully  Partially  Not yet begun

If “fully” or “partially,” could you provide us with an example of how you have been able to do so?

If “not yet begun,” do you intend to implement the information/ideas/skills covered in the meeting in the future?

Yes  No

Have there been any barriers to implementing the information/ideas/skills that you received in the meeting?

If “yes,” please describe.

Yes  No

3. To what extent have the information/ideas/skills that you received improved your capacity to provide effective prevention

services?

 Not At All  Not Very Much  Somewhat  A Great Deal  Not Applicable

4. To what extent have the information/ideas/skills that you received improved your capacity to provide training?

 Not At All  Not Very Much  Somewhat  A Great Deal  Not Applicable

5. Estimate the number of people you have trained since the last Field Trainers meeting on <insert date.>. _____

6. Feel free to add any additional information on how such service could be improved in the future.

Thank you!

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 OMB control number for this project is 0930-0197. Public reporting burden for this collection of information is estimated to average 8 minutes per client per year, 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, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

SAMHSA Fetal Alcohol Spectrum Disorders Center for Excellence

F ASD Field Trainers Meeting Follow-up Protocol

NOTE: This process will be automated as part of the FASD Event Database. The OMB control number and burden statement will appear on the first web page of the form.

E-MAIL INVITATION:

At the SAMHSA FASD Center for Excellence, we are continually working to improve our services. To that end, we would like your feedback on a recent FASD field trainers meeting in which you participated – the <name and description of event> held in <location of event>.

Click on this link to begin the feedback survey: <link to feedback survey>

If you would rather provide your feedback through an interview instead of completing the brief on-line survey, click on the link below to arrange an interview.

Click on this link if you would rather provide your feedback through an interview:

<link to interview page>

If you would prefer not to participate, click on the link below.

Click on this link if you would prefer not to participate: <link to opt-out page>

Thank you in advance for your cooperation. If you have any questions about this process, you can contact <name of contact person> at the SAMHSA FASD Center for Excellence

INTERVIEW PAGE:

If you would prefer not to participate, click on the link below.

Click on this link if you would prefer not to participate: <link to opt-out page>

Thank you in advance for your cooperation. If you have any questions about this process, you can contact <name of contact person> at the Center at 1-866-786-7327.

OPT-OUT PAGE:

If you would prefer not to provide feedback on the field trainers meeting, please check the box below and hit the submit button. Your information will be entered into our system and you will not receive further contacts about this service.

 I would prefer not to provide feedback at this time

REMINDER E-MAIL MESSAGE TO NON-RESPONDENTS (Field Trainers Meeting)

E-MAIL INVITATION:

Dear Colleague:

At the SAMHSA FASD Center for Excellence, we are continually working to improve our services. Our records indicate that we have not yet received your feedback about your experience as a recipient of technical assistance services provided by the SAMHSA FASD Center for Excellence - the <name and description of event> held in <location of event>

It is important for us to obtain information from all recipients in order to ensure that future FASD services meet your needs.

Click on this link to begin the feedback survey: <link to feedback survey>

If you would rather provide your feedback through an interview instead of completing the brief on-line survey, click on the link below to arrange an interview.

Click on this link if you would rather provide your feedback through an interview:

<link to interview page>

If you would prefer not to participate, click on the link below.

Click on this link if you would prefer not to participate: <link to opt-out page>

Thank you in advance for your cooperation. If you have any questions about this process, you can contact <name of contact person> at the SAMHSA FASD Center for Excellence

INTERVIEW PAGE:

If you would prefer not to participate, click on the link below.

Click on this link if you would prefer not to participate: <link to opt-out page>

Thank you in advance for your cooperation. If you have any questions about this process, you can contact <name of contact person> at the Center at 1-866-786-7327.

OPT-OUT PAGE:

 I would prefer not to provide feedback at this time

ATTACHMENT H

TECHNICAL ASSISTANCE FEEDBACK FORM (TECHNICAL ASSISTANCE)

SAMHSA Fetal Alcohol Spectrum Disorders Center for Excellence

T echnical Assistance Feedback Form

Name of Technical Assistance:

Location of Technical Assistance: Date of Technical Assistance:

Technical Assistance Code:

SAMHSA FASD Center for Excellence will be using the unique identification code below to link your answers to information about today’s technical assistance, but will not be able to identify your name or any other information about you. In order to match the pre-, post-, and follow-up evaluation forms, we would like for you to provide the following information. The information will allow matching of the surveys without identifying who you are.

First letter in mother’s first name: ___ First letter in mother’s maiden name: ___

First letter in the city of your birth: ___ First letter in the state of your birth: ___

First letter in your first name: ___

1. What is your gender?  Male  Female

2. Are you Hispanic or Latino?  Yes  No

3. How would you describe your racial background? (Check all that apply.)

 American Indian  Alaska Native  Asian  Black or African American

 Native Hawaiian or Other Pacific Islander  White

4. What is the highest level of education you have completed? (Choose highest level only.)

 Less than high school  High school or equivalent  Associate’s  Bachelor’s

 Master’s  Doctorate  Other post-doctorate

5. Please indicate what field you are in. We have left room next to each choice for you to briefly describe that experience. (Check all that apply.)

 Person living with an FASD

 Direct Caregiver (e.g., parent, grandparent)

 Adult Justice

 Advocacy

 Child Welfare

 Education

 Government

 Housing

 Juvenile Justice

 Media

 Medical/Health Services

 Mental Health Services

 Public Health

 Research

 Retail

 Social Services

 Student

 Substance Abuse Treatment

 Vocational Services

 Other

SATISFACTION WITH TECHNICAL ASSISTANCE

6. Overall, how satisfied are you with the technical assistance that you received?

 Very Dissatisfied  Somewhat Dissatisfied  Somewhat Satisfied  Very Satisfied

7. If you were dissatisfied with the technical assistance, please explain the reason(s) for your dissatisfaction.

UTILITY OF TECHNICAL ASSISTANCE

8. How useful was the technical assistance that you received?

 Very Useful  Somewhat Useful  Not Very Useful  Not at All Useful

9. If the technical assistance was not useful, please explain.

APPLICATION OF TECHNICAL ASSISTANCE

10. We are interested in how the technical assistance you have received from the SAMHSA FASD Center for Excellence has

improved the capacity of your project in the following areas (Choose one for each item)

To what extent has the technical assistance improved your capacity to…	A Great Deal	Somewhat	Not Very Much	Not At All	Not Applicable
Develop a strategic plan to address FASD					
Assist in the development of an FASD Task Force					
Determine prevention and/or treatment needs and assets					
Increase the capacity of your organization to deliver effective prevention programs					
Increase the capacity of your organization to deliver effective treatment programs					
Evaluate your efforts					

11. Please provide any examples of how you may use the technical assistance to improve your capacity in any of these areas.

12. What are potential barriers you may encounter in utilizing the technical assistance provided?

13. How might you overcome these barriers?

14. Do you anticipate utilizing the Center for future technical assistance or training? (Choose one.)

 Yes  No

Thank you!

ATTACHMENT I

FASD technical assistance Follow-up feedback survey

(TECHNICAL ASSISTANCE)

SAMHSA Fetal Alcohol Spectrum Disorders Center for Excellence

FASD Technical Assistance Follow-up Feedback Survey

Name of Technical Assistance Event:

Location of Technical Assistance Event: Date of Technical Assistance Event:

Technical Assistance Event Code:

SAMHSA FASD Center for Excellence will be using the unique identification code below to link your answers to information about the technical assistance, but will not be able to identify your name or any other information about you. In order to match the pre-, post-, and follow-up evaluation forms, we would like for you to provide the following information. The information will allow matching of the surveys without identifying who you are.

First letter in mother’s first name: ___ First letter in mother’s maiden name: ___

First letter in the city of your birth: ___ First letter in the state of your birth: ___

First letter in your first name: ___

Thank you for agreeing to provide us with feedback on the recent FASD event in which you participated.

1. How useful has the information, ideas, or skills that you received in the technical assistance been to you?

 Not at All Useful  Not Very Useful  Somewhat Useful  Very Useful

Comments:

2. To what extent have the technical assistance recommendations you received most recently been fully implemented?

 Fully  Partially  Not yet begun

If “fully” or “partially,” could you provide us with an example of how you have been able to do so?

If “not yet begun,” do you intend to apply the technical assistance recommendations you received in the future?

 Yes  No

3. What, if any, barriers have you experienced thus far to implementing the information/ideas/skills provided through the TA?

4. To what extent has the technical assistance you received improved your capacity to provide effective prevention services?

 Not at All  Not Very Much  Somewhat  A Great Deal  Not Applicable

5. To what extent has the technical assistance you received improved your capacity to provide effective treatment services?

 Not at All  Not Very Much  Somewhat  A Great Deal  Not Applicable

6. To what extent has the technical assistance that you received improved your day-to-day interactions with people with an

FASD and their families?

 Not at All  Not Very Much  Somewhat  A Great Deal  Not Applicable

7. Feel free to add any additional information on how the Center’s technical assistance could be improved in the future.

Thank you!

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 OMB control number for this project is 0930-0197. Public reporting burden for this collection of information is estimated to average 8 minutes per client per year, 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, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

SAMHSA Fetal Alcohol Spectrum Disorders Center for Excellence

F ASD Technical Assistance Follow-up Protocol

NOTE: This process will be automated as part of the FASD Event Database. The OMB control number and burden statement will appear on the first web page of the form.

E-MAIL INVITATION:

At the SAMHSA FASD Center for Excellence, we are continually working to improve our services. To that end, we would like your feedback on a recent FASD technical assistance event in which you participated – the <name and description of event> held in <location of event>.

Click on this link to begin the feedback survey: <link to feedback survey>

If you would rather provide your feedback through an interview instead of completing the brief on-line survey, click on the link below to arrange an interview.

Click on this link if you would rather provide your feedback through an interview:

<link to interview page>

If you would prefer not to participate, click on the link below.

Click on this link if you would prefer not to participate: <link to opt-out page>

Thank you in advance for your cooperation. If you have any questions about this process, you can contact <name of contact person> at the SAMHSA FASD Center for Excellence

INTERVIEW PAGE:

If you would prefer not to participate, click on the link below.

Click on this link if you would prefer not to participate: <link to opt-out page>

Thank you in advance for your cooperation. If you have any questions about this process, you can contact <name of contact person> at the Center at 1-866-786-7327.

OPT-OUT PAGE:

If you would prefer not to provide feedback on the technical assistance event, please check the box below and hit the submit button. Your information will be entered into our system and you will not receive further contacts about this service.

 I would prefer not to provide feedback at this time

REMINDER E-MAIL MESSAGE TO NON-RESPONDENTS (Technical Assistance)

E-MAIL INVITATION:

Dear Colleague:

It is important for us to obtain information from all recipients in order to ensure that future FASD services meet your needs.

Click on this link to begin the feedback survey: <link to feedback survey>

If you would rather provide your feedback through an interview instead of completing the brief on-line survey, click on the link below to arrange an interview.

Click on this link if you would rather provide your feedback through an interview:

<link to interview page>

If you would prefer not to participate, click on the link below.

Click on this link if you would prefer not to participate: <link to opt-out page>

Thank you in advance for your cooperation. If you have any questions about this process, you can contact <name of contact person> at the SAMHSA FASD Center for Excellence

INTERVIEW PAGE:

If you would prefer not to participate, click on the link below.

Click on this link if you would prefer not to participate: <link to opt-out page>

Thank you in advance for your cooperation. If you have any questions about this process, you can contact <name of contact person> at the Center at 1-866-786-7327.

OPT-OUT PAGE:

 I would prefer not to provide feedback at this time

ATTACHMENT J

eVENT REQUESTOR FORM (ALL EVENTS)

SAMHSA Fetal Alcohol Spectrum Disorders Center for Excellence

E vent Requestor Form

The purpose of this form is to obtain your feedback on the SAMHSA FASD Center for Excellence’s process in responding to your request. To protect your confidentiality, your name and any other individually identifying information will not be reported to SAMHSA. It is important to us to obtain this information to maintain and improve the quality of our services; however, your participation is voluntary.

Name of Event:

Location of Event: Date of Event:

Event Code:

Please complete this short feedback form and return it as an e-mail attachment to <name of contact person> at the FASD Center for Excellence. Your response will help us improve the quality of our customer service.

1. Rate the following.
Place an “X” in the appropriate block	Poor	Fair	Good	Excellent	Don’t Know	N/A
Timeliness of our initial response to your request.
Our understanding of your needs.
Responsiveness to your needs throughout the process.
Scheduling a date and time that worked for you.
Usefulness of our recommendations for meeting your needs.
Center staff’s friendliness and helpfulness
Overall quality of the assistance you received from the Center.


2. What suggestions do you have for improving the fasd center’s process for requesting and providing services?

Thank you!

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 OMB control number for this project is 0930-0197. Public reporting burden for this collection of information is estimated to average 4 minutes per client per year, 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, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

File Type	application/msword
File Title	ATTACHMENT A
Author	Vinitha Meyyur
Last Modified By	Vinitha Meyyur
File Modified	2009-02-18
File Created	2009-02-18