Survey #2 Provider Survey #2 Provider View of Workbook

OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

USER SATISFACTION SURVEY
on
DECISION SUPPORT WORKBOOKS
for Mental Health Services Providers
Thank you for taking the time to answer this survey about your experience with use of
the Decision Support Workbooks for support of Shared Decision-Making in Mental
Health Services. We are interested in your experiences with mental health services
consumers who used the What Is Right For Me Workbook. We are also interested in
your experience with the Supporting Choice Workbook, if you used it.
The results from this evaluation will be used to determine whether the Workbooks are
useful for helping people make important decisions and whether they support shared
decision-making in mental health services.
Your participation is VOLUNTARY. You may choose to answer this survey or not.
The information you provide is kept PRIVATE. Your name will not be associated
with this survey. Other information that would let someone identify you will be kept
private. AHP will not share your personal answers with anyone. Reports that explain
the findings of this evaluation will reflect a collection of information from many
participants. This survey will be destroyed after data collection is completed.

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 10
minutes 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 Office, 1 Choke Cherry Road, Room 71044, Rockville, Maryland, 20857.

For Office
Use Only

Date:

Site:

OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

Survey Instructions
You may be asked to skip over some questions in this survey. When this
happens you will see an arrow with a note that tells you what question to answer
next, like this:

Yes → If Yes, go to #1 on page 1
No

Questions
Your Role

Shared Decision-Making

1. What is your primary role with consumers?

3. What information have you read or been
presented with on Shared Decision-Making in
mental health services in the past 6 months?

Peer Support Staff
Medication Prescriber
Therapist or Counselor
Case Manager
Other______________________

Presentation
Brochure
Video
Internet
Journal or Newspaper Article
Other_____________________
I have not seen any information
on Shared Decision-Making

2. What is your education or training
background?
Psychiatrist/M.D.
Nurse
Physician’s Assistant
Psychologist
Social Worker
Other Counseling or Related
Peer Support Training
Other_____________________

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OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

Consumers You Met With
Think about the meetings you had with consumers who used the What Is Right For Me
Workbook and answer the following questions. Estimate numbers as necessary.
4. How many consumers did you meet with who used the What Is Right For Me Workbook
before or during your meeting?
Number of consumers: _________
5. What were the content areas of the decisions you discussed with consumers?
Number of consumers
Mental health treatment or services:

_________

Other (for example, employment or a personal relationship):

_________

6. With how many of the consumers you met with did you discuss a shared decision between you
and the consumer (a decision involving your expertise and recommendation)?
Number of consumers: _________

7. Think about all of the meetings you had with consumers who used the
Workbook and answer the following questions.
a. Do you believe that any of the consumers you met with benefitted
from using the Workbook?

Yes

If yes, how many?

No

_______________

b. Do you believe that, for any of the consumers you met with, use
of the Workbook increased their confidence about making a
decision?

Yes

If yes, how many?

No

_______________

c. Do you believe that, for any of the consumers you met with, use
of the Workbook increased their decision-making skills?

Yes

If yes, how many?

No

_______________

Yes

If yes, how many?

No

_______________

d. Do you believe that, for any of the consumers you met with, use
of the Workbook increased the amount of information they sought
about their decision?

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OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

Think about all of the meetings you had with consumers who used the Workbook
and answer the following questions.
e. Do you believe that, for any of the consumers you met with, use
of the Workbook increased their satisfaction with the decision they
made?

Yes

If yes, how many?

No

_______________

f. Do you believe that, for any of the consumers you met with, use of
the Workbook resulted in improved communication between you
and the consumer?

Yes

If yes, how many?

No

_______________

g. Do you believe that, for any of the consumers you met with, use
of the Workbook resulted in your better understanding their goals?

Yes

If yes, how many?

No

_______________

h. Do you believe that, for any of the consumers you met with, use
of the Workbook resulted in your better understanding their
priorities?

Yes

If yes, how many?

No

_______________

i. Do you believe that, for any of the consumers you met with, use of
the Workbook resulted in your better understanding their values or
beliefs?

Yes

If yes, how many?

No

_______________

k. Did use of the Workbook result in increasing the amount of time
you spent with any consumers?

Yes

If yes, how many?

No

_______________

Yes

If yes, how many?

No

_______________

Yes

If yes, how many?

No

_______________

Yes

If yes, how many?

No

_______________

l. Was this increase in time beneficial for any consumers?

m. Did use of the Workbook result in decreasing the amount of time
you spent with any consumers?

n. Was this decrease in time beneficial for any consumers?

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OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

8. If there was a change in the amount of
time you spent with any consumer due to
their use of the Workbook, did this create a
problem for you?

14. Does the Supporting Choice Workbook
enhance the work you already do to support
consumers in making decisions?
Yes
No

Yes
No
Not Applicable

15. Would you use the Supporting Choice
Workbook again?

9. Would you recommend that other staff
encourage consumers to use the What Is
Right For Me Workbook when they have an
important decision to make?

Yes
No
16. Would you recommend the Supporting
Choice Workbook to other staff?

Yes
No

Yes
No

Supporting Choice Workbook
Your Thoughts

10. Did you use the Supporting Choice
workbook?

17. Is there anything else you think we should
know about your experience with the
Workbooks or with Shared Decision-Making?

Yes
No → If No, go to #17 on this page

__________________________________

11. How many consumers did you use the
Supporting Choice Workbook with?

__________________________________
Number of consumers: ___________
__________________________________
12. Does the Supporting Choice Workbook
contain helpful tips about supporting
decision-making?

__________________________________
__________________________________

Yes
No

__________________________________

13. Is the Supporting Choice Workbook a
useful tool in combination with the What Is
Right For Me Workbook?

You have completed the survey.
Thank you for your participation!

Yes
No

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