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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)


ADVISORY COMMITTEE 


    1. In which SAMHSA Minority Fellowship Program (MFP) have you participated as an Advisory Committee Member?
        a. ___ American Nurses Association
        b. ___ American Psychiatric Association
        c. ___ American Psychological Association
        d. ___ 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
        a. 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