Attachments G & H

Evaluation of SAMHSA’s Minority Fellowship Program (MFP)

OMB Submission

OTHER INFORMATION AND RESOURCES:

• Attachment G Example survey page displaying the OMB control number, expiration date, and burden statement

• Attachment H Membership Lists: Advisory Panel and Subject Matter Experts

Attachment G

Example survey page

(Displaying the OMB control number, expiration date, and burden statement)

Form Approved

OMB NO. 0930-XXXX

Exp. Date MM/DD/YY

See burden statement at the bottom of this page

ADVISORY COMMITTEE

1. In which SAMHSA Minority Fellowship Program (MFP) have you participated as an Advisory Committee Member?

   1. ___ American Nurses Association

   2. ___ American Psychiatric Association

   3. ___ American Psychological Association

   4. ___ Council on Social Work Education

2. On a scale of 1 to 5, with 1 being very unfamiliar to 5 being very familiar, how familiar are you with the MFP sponsored by SAMHSA?

Very Unfamiliar………………………………Very Familiar

1 2 3 4 5

3. Were you an MFP Fellow yourself? ___ Yes ___ No

   1. If yes: in what years did you receive an MFP Fellowship? ______ to ______ for a total of ___ years

4. When did you first become a member of the Advisory Committee? ______

5. How long have you been (or were you) a member of the Advisory Committee? ______ years

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 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 H

Membership Lists: Advisory Panel and Subject Matter Experts

Subject Matter Experts (SME):

Faye Zollicoffer Belgrave

Virginia Commonwealth Univ.

Department of Psychology

William A. Cloud

University of Denver

Graduate School of Social Work

Catherine Alicia Georges, EdD,RN,FAAN

Lehman College

Department of Nursing

Russell Fun Lim, BS, MEd, MD

University of California, Davis School of Medicine

Department of Psychiatry and Behavioral Sciences

Advisory Panel Members:

Deborah Altschul, PhD

University of Hawaii at Manoa

Department of Psychology

Kinike Bermudez

Garland, TX

Majose Carrasco

NAMI Multicultural Action Center

Arlington, VA

KERMIT A. CRAWFORD, PH.D.

Boston University

Center for Multicultural Mental Health at Boston Medical Center

Pablo Hernandez, MD

Wyoming State Hospital

Spero M. Manson, Ph.D.
University of Colorado/Denver

American Indian and Alaska Native Programs

John A. Morris, MSW
University of South Carolina School of Medicine
Department of Neuropsychiatry and Behavioral Science

217