Form Attachment 3 - Cli Attachment 3 - Cli Attachment 3 - Client Survey
Access to Recovery (ATR) Program Cross-Site Evaluation
Attachment 3_Client Survey
ATR Evaluation
OMB: 0930-0299
Attachment 3:
Client Survey
OMB NO. 0930-XXXX
Exp. Date XX/XX/XX
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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-xxxx. Public reporting burden for this collection of information is estimated to average .15 hours 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.
GPRA ID Number _____________________________
INSTRUCTIONS:
To help us learn about the [Grantee’s ATR Program] we would like you to answer the following 11 questions. These questions ask about your provider choices and your experiences with the [Grantee’s ATR Program].
These questions should take you about 6 minutes to complete.
Your answers will not be shared. Answering this survey will not affect the services you may receive through the [Grantee’s ATR Program].
Please begin survey on the next page
Clinical Treatment Services |
The following questions ask about your choices of treatment providers for the clinical treatment services you may have received through the [Grantee’s ATR Program].
Clinical treatment services may include [will vary based on services provided by a Grantee’s ATR Program and will likely include some of the following: counseling (e.g., individual, group, family/marriage), detox (e.g., inpatient, ambulatory, residential), inpatient treatment, residential treatment, outpatient treatment, and medication for substance abuse (e.g., methadone, buprenorphine).]
1. Did you receive clinical treatment services through the [Grantee’s ATR Program]?
1 Yes
2 No Go to Question 5 (next page)
2. Thinking back to when you entered the [Grantee’s ATR Program], were you given a choice about which clinical provider(s) you could go to?
1 Yes
2 No Go to Question 5 (next page)
97 Not sure
3. Did you have the option of choosing a clinical provider to which you had no religious and/or cultural objection? 1 Yes 2 No 97 Not sure
|
4. Did you select your clinical treatment provider because… (Please mark all that apply)
-
Yes
No
a. They were conveniently located.
1
2
b. They had the shortest or no wait time.
1
2
c. Their services were available at convenient times.
1
2
d. They helped get me into the [Grantee’s ATR Program].
1
2
e. They shared my religious beliefs.
1
2
f. They shared my cultural or traditional beliefs.
1
2
g. My case manager or other agency staff recommended them.
1
2
h. Friends or family recommended them.
1
2
i. My pastor, clergy, spiritual leader, or tribal elder recommended them.
1
2
j. They have a good reputation in the community.
1
2
k. They have treated me in the past.
1
2
l. They had the best services for me.
1
2
m. They were run by the tribe
1
2
n. They were located on my reservation or in my village
1
2
o. Other, please specify__________________________________________
1
2
Please continue
Recovery Support Services |
The next questions ask about your choice of providers for the recovery support services you may have received through the [Grantee’s ATR Program].
Recovery support services may include [will vary based on services provided by a Grantee’s ATR Program and will likely include some of the following: case management, family services (e.g., child care), employment assistance, transportation, housing assistance, medical services (e.g., alcohol or drug testing), HIV/AIDS support and testing, aftercare services such as relapse prevention or self-help, religious or faith-based support, Native American/cultural services, peer-to-peer support, and/or support groups.]
5. Did you receive recovery support services through the [Grantee’s ATR Program]?
1 Yes
2 No Go to Question 9 (next page)
6. Thinking back to when you entered the [Grantee’s ATR Program], were you given a choice about which recovery support provider(s) you could go to?
1 Yes
2 No Go to Question 9 (next page)
97 Not sure
7. Did you have the option of choosing a clinical provider to which you had no religious and/or cultural objection? 1 Yes 2 No 97 Not sure |
8. Did you select your clinical treatment provider because… (Please mark all that apply)
-
Yes
No
a. They were conveniently located.
1
2
b. They had the shortest or no wait time.
1
2
c. Their services were available at convenient times.
1
2
d. They helped get me into the [Grantee’s ATR Program].
1
2
e. They shared my religious beliefs.
1
2
f. They shared my cultural or traditional beliefs.
1
2
g. My case manager or other agency staff recommended them.
1
2
h. Friends or family recommended them.
1
2
i. My pastor, clergy, spiritual leader, or tribal elder recommended them.
1
2
j. They have a good reputation in the community.
1
2
k. They have treated me in the past.
1
2
l. They had the best services for me.
1
2
m. They were run by the tribe
1
2
n. They were located on my reservation or in my village
1
2
o. Other, please specify__________________________________________
1
2
Please continue
Overall ATR Program Experience |
The following questions ask about your experience and satisfaction getting services (either clinical or recovery support) from the [Grantee’s ATR Program].
9. Please mark the choice that best describes your thoughts on your experience and satisfaction with the [Grantee’s ATR Program].
-
MARK ONE ANSWER FOR EACH
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
Not Applicable
a. I had enough information to make a good choice about which provider to use.
1
2
3
4
5
9
b. Getting [Grantee’s ATR Program] services and choosing my provider(s) was easy
1
2
3
4
5
9
c. Getting answers to questions about [Grantee’s ATR Program] was easy.
1
2
3
4
5
9
d. I would not have been able to receive services without the [Grantee’s ATR Program].
1
2
3
4
5
9
e. I was satisfied with choices I had for service providers.
1
2
3
4
5
9
f. I got services that I needed through the [Grantee’s ATR Program].
1
2
3
4
5
9
g. I would recommend the [Grantee’s ATR Program] to others who need similar services.
1
2
3
4
5
9
h. Overall, I am satisfied with the [Grantee’s ATR Program]…………
1
2
3
4
5
9
10. If you were not satisfied with the [Grantee’s ATR Program], please tell us why.
Please continue
11. If you have suggestions or comments you’d like to share about the [Grantee’s ATR Program], please write them below.
Thank you very much for your time and participation!
| File Type | application/msword |
| File Title | ATTACHMENT 3: |
| Author | sorme |
| Last Modified By | sorme |
| File Modified | 2008-10-15 |
| File Created | 2008-10-15 |
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