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OMB No. 0930-0197, Exp. Date 01/31/2011

Substance Abuse Mental Health Services Administration (SAMHSA)

Center for Mental Health Services (CMHS)

Government Performance Results Act (GPRA)

Survey of Satisfaction with CMHS Technical Assistance

a.

This survey is an annual CMHS GPRA data collection. It is intended to assess your satisfaction with the Technical Assistance (TA) provided by <TA Provider’s Organization Name> to you and/or your grant staff during Federal Fiscal Year (FFY) <200X> <(dates of the corresponding year)>. Individual responses will be kept secret from CMHS staff and TA providers; results of the survey will only be presented in aggregate form so that individual responses cannot be identified.

The survey will require no more than 10 minutes to complete.

For questions regarding this survey please contact the TRAC Help Desk at 1-888-219-0238 or [email protected].

For further information regarding CMHS go to: http://mentalhealth.samhsa.gov/cmhs/.

For further information regarding SAMHSA’s National Outcome Measures (NOMs) go to:

http://nationaloutcomemeasures.samhsa.gov/outcome/index_2007.asp.

b.

Public Burden Statement: 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 .16 per respondent 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.

1. Did <TA Provider’s organization name> provide the following types of TA to you or your grant staff during Federal Fiscal Year (FFY) <’09> <(10/2008 – 9/2009)>?

	Yes	No	Don’t Know	Not Applicable
Regular, Ongoing Consultation/Discussion	○	○	○	○
Customized TA	○	○	○	○
Trainings, Webinars and Other Events	○	○	○	○
Annual or Semi-Annual Grantee Meetings	○	○	○	○
Resource Materials	○	○	○	○
Information or Support Via the TA Provider’s Website	○	○	○	○
Site Visits	○	○	○	○
Other (SPECIFY) ___________________________________	○	○	○	○

2. Did you or your grant staff need or want any of the following types of TA during Federal Fiscal Year (FFY) <’09> <(10/2008 – 9/2009)>?

	Yes	No	Don’t Know	Not Applicable
Regular, Ongoing Consultation/Discussion	○	○	○	○
Customized TA	○	○	○	○
Trainings, Webinars and Other Events	○	○	○	○
Annual or Semi-Annual Grantee Meetings	○	○	○	○
Resource Materials	○	○	○	○
Information or Support Via the TA Provider’s Website	○	○	○	○
Site Visits	○	○	○	○
Other (SPECIFY) ___________________________________	○	○	○	○

< If ‘yes’ is not selected for at least one type in #1, after the respondent answers #2, the survey will be programmed to skip to #11. >

< The web survey will be programmed to prefill only the categories the respondents indicated ‘yes’ to in #1 (TA that was provided). >

3. Please indicate your level of agreement with the statement below for each of the following types of TA.

The TA provided by <TA Provider’s organization name> during FFY<’09> <(10/2008 – 9/2009)> was useful to carrying out the grant successfully.

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
Regular, Ongoing Consultation/Discussion	○	○	○	○	○
Customized TA	○	○	○	○	○
Trainings, Webinars and Other Events	○	○	○	○	○
Annual or Semi-Annual Grantee Meetings	○	○	○	○	○
Resource Materials	○	○	○	○	○
Information or Support Via the TA Provider’s Website	○	○	○	○	○
Site Visits	○	○	○	○	○
Other (SPECIFY) ____________________________________	○	○	○	○	○

4. (a.) Did <TA Provider’s organization name> provide TA in the following domains to you or your grant staff during FFY<’09> <(10/2008 – 9/2009)>?

	Yes	No	Don’t Know	Not Applicable
Decreasing Criminal Justice Involvement	○	○	○	○
Improving Access to Services or Service Capacity	○	○	○	○
Improving Client Perception of Care	○	○	○	○
Improving Cost Effectiveness	○	○	○	○
Improving Consumer Functioning	○	○	○	○
Increasing Consumer Social Supports/Social Connectedness	○	○	○	○
Increasing or Retaining Consumer Employment or Returning to/Staying in School	○	○	○	○
Increasing Stability in Housing	○	○	○	○
Increasing the Use of Evidence-Based Practices	○	○	○	○
Reducing Consumer Utilization of Psychiatric Hospitalization	○	○	○	○

(b.) Did <TA Provider’s organization name> provide TA on the following topics to you or your grant staff during FFY<’09> <(10/2008 – 9/2009)>?

	Yes	No	Don’t Know	Not Applicable
Addressing Co-occurring Mental Health and Substance Use Disorders	○	○	○	○
Building and Maintaining Coalitions	○	○	○	○
Conducting Project Evaluation	○	○	○	○
Developing or Implementing Cultural Competence/Appropriateness	○	○	○	○
Developing or Implementing Communications and Social Marketing	○	○	○	○
Developing Sustainability Plans	○	○	○	○
Financing	○	○	○	○
Identifying/Selecting Best Practices Programs	○	○	○	○
Implementing Best Practices Programs	○	○	○	○
Implementing Sustainability Plans	○	○	○	○
Involving Consumer, Family, & Youth in Policy, Programs and Evaluation	○	○	○	○
Making Services Consumer-, Family-, & Youth-Driven	○	○	○	○
Needs Assessment	○	○	○	○
Project Management	○	○	○	○
Strategic Planning	○	○	○	○
Workforce Development	○	○	○	○
Other (SPECIFY) ____________________________________	○	○	○	○

< The web survey will be programmed to prefill only the categories the respondents indicated ‘yes’ to in #4a (TA that was provided.) >

5. (a.) Please indicate your level of agreement with the statement below for each of the following domains of TA.

The TA provided by <TA Provider’s organization name> during FFY<’09> <(10/2008 – 9/2009)> was useful to carrying out the grant successfully.

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
Decreasing Criminal Justice Involvement	○	○	○	○	○
Improving Access to Services or Service Capacity	○	○	○	○	○
Improving Client Perception of Care	○	○	○	○	○
Improving Cost Effectiveness	○	○	○	○	○
Improving Consumer Functioning	○	○	○	○	○
Increasing Consumer Social Supports/Social Connectedness	○	○	○	○	○
Increasing or Retaining Consumer Employment or Returning to/Staying in School	○	○	○	○	○
Increasing Stability in Housing	○	○	○	○	○
Increasing the Use of Evidence-Based Practices	○	○	○	○	○
Reducing Consumer Utilization of Psychiatric Hospitalization	○	○	○	○	○

< The web survey will be programmed to prefill only the categories the respondents indicated ‘yes’ to in #4b (TA that was provided.) >

(b.) Please indicate your level of agreement with the statement below for each of the following subjects of TA.

The TA provided by <TA Provider’s organization name> during FFY<’09> <(10/2008 – 9/2009)> was useful to carrying out the grant successfully.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Addressing Co-occurring Mental Health and Substance Use Disorders

○

○

○

○

○

Building and Maintaining Coalitions	○	○	○	○	○
Conducting Project Evaluation	○	○	○	○	○
Developing or Implementing Cultural Competence/Appropriateness	○	○	○	○	○
Developing or Implementing Communications and Social Marketing	○	○	○	○	○
Developing Sustainability Plans	○	○	○	○	○
Financing	○	○	○	○	○
Identifying/Selecting Best Practices Programs	○	○	○	○	○
Implementing Best Practices Programs	○	○	○	○	○
Implementing Sustainability Plans	○	○	○	○	○
Involving Consumer, Family, & Youth in Policy, Programs and Evaluation	○	○	○	○	○
Making Services Consumer-, Family-, & Youth-Driven	○	○	○	○	○
Needs Assessment	○	○	○	○	○
Project Management	○	○	○	○	○
Strategic Planning	○	○	○	○	○
Workforce Development	○	○	○	○
Other (SPECIFY) _____________________________________	○	○	○	○	○

6. Did <TA Provider’s organization name> perform the following activities during FFY<’09> <(10/2008 – 9/2009)>?

	Yes	No	Don’t Know	Not Applicable
Asked you what TA you needed prior to providing TA to your grant	○	○	○	○
Designated a specific person to work with your grant	○	○	○	○

7. Please indicate your level of agreement with the following statements.

During FFY<’09> <(10/2008 – 9/2009)>, <TA Provider’s organization name> always…

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
Understood my project’s goals and objectives.	○	○	○	○	○
Understood the culture and/or unique needs of the population served by my project.	○	○	○	○	○
Fostered a trusting, reciprocal relationship.	○	○	○	○	○
Used productive two-way communication.	○	○	○	○	○
Demonstrated a positive attitude in delivering TA.	○	○	○	○	○
Provided a process for ongoing planning, feedback, and discussion.	○	○	○	○	○
Provided services in a timely manner.	○	○	○	○	○

8. Please indicate your level of agreement with the following statements.

During FFY<’09> <(10/2008 – 9/2009)>, <TA Provider’s organization name> always…

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
Helped enhance the ability of my project to perform the grant.	○	○	○	○	○
Applied research based knowledge and content, best practices, and resources.	○	○	○	○	○
Provided targeted information, services, and resources based on my project’s objectives.	○	○	○	○	○
Made sure that project staff understood what needed to be achieved this year.	○	○	○	○	○
Promoted consumer/family or youth involvement within my project.	○	○	○	○	○
Helped my project to develop a grantee network.	○	○	○	○	○

9. Please indicate your level of agreement with the following statements.

The TA provided by <TA Provider’s organization name> during FFY<’09> <(10/2008 – 9/2009)> enabled our grant staff to…

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
Gain additional knowledge.	○	○	○	○	○
Gain additional skills.	○	○	○	○	○
Apply newly acquired knowledge.	○	○	○	○	○
Apply newly acquired skills.	○	○	○	○	○
Achieve positive programmatic outcomes.	○	○	○	○	○

10. Please list any other TA types or subjects received by you or your grant staff that are not listed in this survey.

11. Please list other TA types or subjects for which you would like to receive TA.

12. Additional comments:

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