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 I Consent Form
Attachment J Telephone Script
Attachment K Letter of Invitation: Email
Attachment L Letter of Invitation: US mail
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
In which SAMHSA Minority Fellowship Program (MFP) have you participated as an Advisory Committee Member?
___ American Nurses Association
___ American Psychiatric Association
___ American Psychological Association
___ Council on Social Work Education
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
Were you an MFP Fellow yourself? ___ Yes ___ No
If yes: in what years did you receive an MFP Fellowship? ______ to ______ for a total of ___ years
When did you first become a member of the Advisory Committee? ______
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
Attachment I
Consent Forms
Current SAMHSA MFP Fellows
Informed Consent Form
Purpose of the Evaluation:
This is an evaluation that is being conducted by the Human Services Research Institute in Cambridge, Massachusetts for the federal Substance Abuse and Mental Health Services Administration (SAMHSA). The purpose of this evaluation is to examine the effectiveness of the SAMHSA funded Minority Fellowship Program (MFP). You have been selected for this evaluation because you are a current MFP Fellow.
What will be done:
You will complete a survey, which will take 90 minutes to complete. The survey includes questions about your experiences in the MFP (from recruitment into the program through your participation in the various activities provided by the [American Nurses Association (ANA), American Psychiatric Association (ApA), the American Psychological Association (APA), and the Council on Social Work Education (CSWE)].
Benefits of this Evaluation:
You will be contributing to knowledge about the SAMHSA funded MFP.
Risks or discomforts:
No risks or discomforts are anticipated from taking part in this evaluation. If you feel uncomfortable with a question, you can skip that question or withdraw from the evaluation altogether without any consequences to you.
Confidentiality:
Your responses will be kept completely confidential. Any information that we learn about you that can be traced to you will be used responsibly and will be protected against release to unauthorized persons.
Decision to quit at any time:
Your participation is voluntary; you are free to withdraw your participation from this evaluation at any time. If you do not want to continue, you can simply leave this website. You may also choose to skip any questions that you do not wish to answer.
How the findings will be used:
The results of this evaluation will be reported to SAMHSA. The results from the study might be presented at professional conferences and published in a professional journal in the field of mental health and substance abuse.
Contact information:
If you have concerns or questions about this evaluation, please contact Terry Camacho-Gonsalves at [email protected] or at (617)-844-2504.
By beginning the survey, you acknowledge that you have read this information and agree to participate in this research, with the knowledge that you are free to withdraw your participation at any time.
SAMHSA MFP Alumni
Informed Consent Form
Purpose of the Evaluation:
This is an evaluation that is being conducted by the Human Services Research Institute in Cambridge, Massachusetts for the federal Substance Abuse and Mental Health Services Administration (SAMHSA). The purpose of this evaluation is to examine the effectiveness of the SAMHSA funded Minority Fellowship Program (MFP). You have been selected for this evaluation because you are Alumni of the SAMHSA MFP.
What will be done:
You will complete a survey, which will take two hours to complete. The survey includes questions about your experiences in the MFP (from recruitment into the program through your participation in the various activities provided by the [American Nurses Association (ANA), American Psychiatric Association (ApA), the American Psychological Association (APA), and the Council on Social Work Education (CSWE)].
Benefits of this Evaluation:
You will be contributing to knowledge about the SAMHSA funded MFP.
Risks or discomforts:
No risks or discomforts are anticipated from taking part in this evaluation. If you feel uncomfortable with a question, you can skip that question or withdraw from the evaluation altogether.
Confidentiality:
Your responses will be kept completely confidential. Any information that we learn about you that can be traced to you will be used responsibly and will be protected against release to unauthorized persons.
Decision to quit at any time:
Your participation is voluntary; you are free to withdraw your participation from this evaluation at any time without any consequences to you. If you do not want to continue, you can simply leave this website You may also choose to skip any questions that you do not wish to answer.
How the findings will be used:
The results of this evaluation will be reported to SAMHSA. The results from the study might be presented at professional conferences and published in a professional journal in the field of mental health and substance abuse.
Contact information:
If you have concerns or questions about this evaluation, please contact Terry Camacho-Gonsalves at [email protected] or at (617)-844-2504.
By beginning the survey, you acknowledge that you have read this information and agree to participate in this research, with the knowledge that you are free to withdraw your participation at any time.
SAMHSA MFP Selection and Advisory Committee Member
Informed Consent Form
Purpose of the Evaluation:
This is an evaluation that is being conducted by the Human Services Research Institute in Cambridge, Massachusetts for the federal Substance Abuse and Mental Health Services Administration (SAMHSA). The purpose of this evaluation is to examine the effectiveness of the SAMHSA funded Minority Fellowship Program (MFP). You have been selected for this evaluation because you are a member of the MFP Selection and/or Advisory Committee.
What will be done:
You will complete a survey, which will take 90 minutes to complete. The survey includes questions about your experiences in the MFP (from recruitment into the program through your participation in the various activities provided by the [American Nurses Association (ANA), American Psychiatric Association (ApA), the American Psychological Association (APA), and the Council on Social Work Education (CSWE)].
Benefits of this Evaluation:
You will be contributing to knowledge about the SAMHSA funded MFP.
Risks or discomforts:
No risks or discomforts are anticipated from taking part in this evaluation. If you feel uncomfortable with a question, you can skip that question or withdraw from the evaluation altogether.
Confidentiality:
Your responses will be kept completely confidential. Any information that we learn about you that can be traced to you will be used responsibly and will be protected against release to unauthorized persons.
Decision to quit at any time:
Your participation is voluntary; you are free to withdraw your participation from this evaluation at any time without any consequences to you. If you do not want to continue, you can simply leave this website. You may also choose to skip any questions that you do not wish to answer.
How the findings will be used:
The results of this evaluation will be reported to SAMHSA. The results from the study might be presented at professional conferences and published in a professional journal in the field of mental health and substance abuse.
Contact information:
If you have concerns or questions about this evaluation, please contact Terry Camacho-Gonsalves at [email protected] or at (617)-844-2504.
By beginning the survey, you acknowledge that you have read this information and agree to participate in this research, with the knowledge that you are free to withdraw your participation at any time.
Attachment J
Telephone Script
Good morning/afternoon.
My name is _____________________ and I am a ______________ at Human Services Research Institute. As you know we are conducting an evaluation of the Substance Abuse and Mental Health Services Administration (SAMHSA) funded Minority Fellowship Program (MFP).
I am calling to invite you to participate in an interview. We are asking questions about your knowledge and involvement with the MFP. The information provided will be used to examine the effectiveness of the MFP. You have been chosen for the interview because you are a [current or former SAMHSA MFP Staff or other SAMHSA official; current or former MFP Program Director or Senior Staff; staff in the MFP grantee’s host organization [American Nurses Association (ANA), American Psychiatric Association (ApA), the American Psychological Association (APA), and the Council on Social Work Education (CSWE)].
The interview will take about 2 hours and any information you give me will be confidential and your name and any other identifying information will not be revealed. If you have any concerns or questions about this evaluation, I will provide you with a telephone number for you to call to get more information. While your participation is voluntary, your experiences are valuable and will help us in the evaluation. Is this a good time to talk?
(IF YES) By beginning the interview, you agree to participate in this evaluation with the knowledge that you are free to withdraw your participation at any time without any consequences to you.
(IF NO) Would there be a better time for us to talk?
Attachment K
Letter of Invitation: Email
Good morning/afternoon!
The Substance Abuse and Mental Health Services Administration (SAMHSA) has contracted with the Human Services Research Institute (HSRI) in Cambridge, Massachusetts to conduct an evaluation of the SAMHSA-funded Minority Fellowship Program (MFP).
The purpose of this evaluation is to examine the effectiveness of the MFP. You have been selected for this evaluation because you are a [current MFP Fellow; Alumni of the MFP; member of the MFP Selection or Advisory Committee]. We are contacting all [current MFP Fellows; Alumni of the MFP; members of the MFP Selection or Advisory Committee]. As part of this evaluation, we are writing to invite you to participate in a survey about the MFP.
The survey consists of a number of questions and will take approximately 90 minutes [or two hours] for you to complete. All individual responses will be kept strictly confidential and your name and any other identifying information will not be revealed If you feel uncomfortable with a question, you can skip that question or withdraw from the evaluation altogether. To complete the electronic survey, click on the link below which will connect you to the HSRI website and our survey. Once connected, you will find specific instructions on how to complete the survey online.
While your participation is voluntary, your input is critical to assessing the effectiveness of the MFP. Please complete the survey within the next 10 business days. We want to thank you in advance for your participation and feedback and look forward to sharing results with SAMHSA.
LINK
Please use the following username and password:
USERNAME:
PASSWORD:
If you prefer to complete the survey in hardcopy and return it by mail, please contact Terry Camacho-Gonsalves at [email protected] or at (617) 844-2504 to request a copy of the survey.
In addition, if you have any questions, please contact Terry Camacho-Gonsalves at the above number or e-mail address.
Thank you in advance for participating and helping in the evaluation of the MFP.
Regards
Attachment K
Letter of Invitation: US Mail
Evaluation of the SAMHSA’s Minority Fellowship Program (MFP)
Letter of Invitation: U.S. Mail
Dear ________,
The Substance Abuse and Mental Health Services Administration (SAMHSA) has contracted with the Human Services Research Institute (HSRI) in Cambridge, Massachusetts to conduct an evaluation of the SAMHSA-funded Minority Fellowship Program (MFP).
The purpose of this evaluation is to examine the effectiveness of the MFP. You have been selected for this evaluation because you are a [current MFP Fellow; Alumni of the MFP; member of the MFP Selection or Advisory Committee]. We are attempting to contact all [current MFP Fellows; Alumni of the MFP; members of the MFP Selection or Advisory Committee]. As part of this evaluation, we are inviting you to participate by completing a survey.
The survey will take approximately 90 minutes [or two hours] for you to complete. All individual responses will be kept strictly confidential and your name and any other identifying information will not be released. If you feel uncomfortable with a question, you can skip that question or withdraw from the evaluation altogether.
To complete the electronic survey, please visit the following web address to connect to the HSRI website and the on-line survey:
Insert link
Please use the following username and password:
USERNAME:
PASSWORD:
Your input is critical to assessing the effectiveness of the MFP. Please complete the survey within the next 10 business days. We want to thank you in advance for your participation and feedback and look forward to sharing results with SAMHSA.
If you prefer to complete the survey in hardcopy and return it by mail, find attached a copy of the informed consent, survey, and a return envelope with postage.
If you have any questions or concerns about this evaluation please contact Terry Camacho-Gonsalves at [email protected] or at (617) 844-2504.
Thank you in advance for participating and helping in the evaluation of the MFP.
With kind regards,
Signature
Name
Address
Phone Number
e-mail address
| File Type | application/msword |
| Author | epell |
| Last Modified By | Owner |
| File Modified | 2009-09-18 |
| File Created | 2009-09-15 |