Adherence Participant Feedback Form

Center for Mental Health Services
Adherence Participant Feedback Form
Instructions
The training you are attending is funded by The Center for Mental Health
Services (CMHS), a Federal agency with a mission to improve mental health
services delivered to HIV/AIDS affected populations. CMHS requests that you
complete the attached form in order to assist in assessing the effectiveness of the
effort in meeting its objectives to provide state-of-the-art information to a
diverse mixture of training participants. CMHS and the sponsoring agency
intend to use the information gathered from this feedback to improve the quality
of training and to ensure continued funding for HIV/AIDS provider education
programs.
Public reporting burden for this collection of information is estimated to average
10 minutes per response, including time for reviewing instructions and
completing the feedback form. 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; Paperwork
Reduction Project (0930-0195); Room 16-105, Parklawn Building; 5600 Fishers
Lane, Rockville, MD 20857. 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 0930-0195.
Completion of the feedback form is voluntary. All information gathered from
the form is anonymous. It is important that you fill in the Anonymous
Unique Identifier at the top of the form. This identifier will be used to
match your responses from this form with responses from other forms that
you may complete as part of this training. Please use a pen or pencil to darken
each circle completely. Return the completed form to the place designated by the
training staff.
Thank you, your help is appreciated.

Substance Abuse and Mental Health Services Administration

Mental Health Care Provider
Education in HIV/AIDS
Program