Form Web-based training Web-based training Web-based training material-instruments

ATTACHMENT H
PRE-TRAINING EVALUATION FORM
FOR WEB-BASED SOAR TRAINING

OMB No. 0930-XXXX
Expiration Date XX/XX/XXXX

Pre-Training Evaluation Form
Stepping Stones to Recovery
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 10 minutes per
respondent, 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. All aspects of
your participation in this study are voluntary; you will not be penalized in any way by refusing to complete any portion of
this form.

Date: _____________________________________Location: __________________________
Training Team: ________________________________________________________________
1.

I learned about this training from… Check all that apply.
____My supervisor
____SOAR leader contacted me
____SOAR website
____ Web-based SOAR training
____ In-person SOAR training
____Other: please describe_____________________

2.

I have support from my supervisor to participate in this training during regular work
hours. Circle one
Yes
No

3.

I work at an agency that is primarily a... Circle one
1. Mental health agency
2. Homeless service agency

4.

SSA or DDS office
Other (please specify) _________________

At the above agency, my current job is ... Circle one
1. Outreach worker
2. Case Manager

5.

3.
4.

3. Shelter Worker
4. Benefits Specialist

5. Program Coordinator/Supervisor
6. Other (specify)_______________

I have worked at this job for… Circle one
1. Less than 1 year

Policy Research Associates, Inc

2. 1-5years

3. More than 5 years

H-1

4/7/2011

OMB No. 0930-XXXX
Expiration Date XX/XX/XXXX

Circle one Yes

6.

I have experience working with clients who are homeless?

7.

I have experience working with clients who have mental health problems. Circle one
Yes

No

No

8.

My position is PATH-funded? Circle one

9.

I have the following experience with SOAR training. Check all that apply.

Yes

No

Don't Know

____None
____I have completed some or all of the web-based SOAR training
____I have participated in a two-day SOAR in-person training
____I have participated in a one-day SOAR in-person training
____I have participated in an abbreviated version (less than one day) of SOAR training
10. I have assisted the following number of adults with SSI or SSDI applications in the past
year. Circle one
1. None
2. Less than 1 per month

3. About 1 per month
4. About 2 or 3 per month

5. More than 3 per month

11. The approximate proportion of adult SSI or SSDI applications I have assisted with are
typically approved on initial application. Circle one
1. None
2. 1 - 25 percent

3. 26 - 50 percent
4. 51 - 75 percent

5. 76 - 100 percent
6. Not applicable

12. For applications I have assisted with, the approximate length of time between
application and initial decision is… Circle one
1. 3 months or less
2. 4-6 months

Policy Research Associates, Inc

3. 7-12 month
4. More than 12 months

H-2

5. Not applicable

4/7/2011

OMB No. 0930-XXXX
Expiration Date XX/XX/XXXX
Answer the questions below to the best of your ability. The answers
will be provided to you at the end of the training session.

Circle One

1. If an applicant is currently using alcohol or drugs, or has a recent
history of substance use, he/she can still be eligible for SSI or
SSDI.

T

F

2. If you become the applicant’s representative using the SSA-1696
form during the application process, you will also become the
applicant’s representative payee when he/she is approved for SSI
or SSDI.

T

F

3. People who try to work usually keep some of their SSI/SSDI
benefits and their health insurance.

T

F

4. As a general rule, everyone is denied SSI and SSDI benefits the
first time they apply.

T

F

5. A diagnosis of mental illness is not sufficient to determine disability.

T

F

6. For people with mental illness, the application should include
information on all health issues.

T

F

7. To be successful with the application, the case manager must
focus solely on the SSA forms.

T

F

8. For both SSI and SSDI, the date of eligibility is determined in the
same way.

T

F

9. A description of functional ability can help the Disability
Determination Services determine if someone is capable of
engaging in substantial gainful activity.

T

F

10. A record of felony convictions makes a person ineligible for SSA
benefits.

T

F

OMB Draft
February 17, 2010

Policy Research Associates, Inc

H-3

4/7/2011

ATTACHMENT I
POST-TRAINING EVALUATION FORM
FOR WEB-BASED SOAR TRAINING

OMB No. 0930-XXXX
Expiration Date XX/XX/XXXX

Post-Training Evaluation Form
Stepping Stones to Recovery
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 10 minutes per
respondent, 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. All aspects of
your participation in this study are voluntary; you will not be penalized in any way by refusing to complete any portion of
this form.

Date: _________________________________Location: _______________________________
Training Team: _________________________________________________________________
Answer the questions below to the best of your ability. The answers will be
provided to you at the end of the training session.

Circle One

1.

If an applicant is currently using alcohol or drugs, or has a recent
history of substance use, he/she can still be eligible for SSI or SSDI.

T

F

2.

If you become the applicant’s representative using the SSA-1696 form
during the application process, you will also become the applicant’s
representative payee when he/she is approved for SSI or SSDI.

T

F

3.

People who try to work usually keep some of their SSI/SSDI benefits
and their health insurance.

T

F

4.

As a general rule, everyone is denied SSI and SSDI benefits the first
time they apply.

T

F

5.

A diagnosis of mental illness is not sufficient to determine disability.

T

F

6.

For people with mental illness, the application should include
information on all health issues.

T

F

7.

To be successful with the application, the case manager must focus
solely on the SSA forms.

T

F

8.

For both SSI and SSDI, the date of eligibility is determined in the same
way.

T

F

9.

A description of functional ability can help the Disability Determination
Services determine if someone is capable of engaging in substantial
gainful activity.

T

F

T

F

10. A record of felony convictions makes a person ineligible for SSA
benefits.

OMB Draft
February 17, 2010

Policy Research Associates, Inc

I-1

4/7/2011

ATTACHMENT J
CUSTOMER SATISFACTION SURVEY
FOR WEB-BASED SOAR TRAINING

OMB No. 0930-XXXX
Expiration Date XX/XX/XXXX

Satisfaction with SSR Training Survey [Web-based]
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 10 minutes per
respondent, 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. All aspects of
your participation in this study are voluntary; you will not be penalized in any way by refusing to complete any portion of
this survey.
Check Only One
To what extent do you agree disagree with each statement below as it relates to this
training?
I.
1.

Training Evaluation Questions
I have a better understanding of the differences between SSI and
SSDI including the health insurance offered and eligibility
requirements.

Strongly
Disagree

Disagree

Agree

Strongly
Agree

1

2

3

4

2.

I am better able to identify the non-medical criteria for SSI/SSDI
eligibility.

1

2

3

4

3.

I have a better understanding of the disability determination
process and how to develop medical information to support a
disability claim.

1

2

3

4

4.

I have a clearer understanding of the role of functional information
in the determination of disability.

1

2

3

4

5.

I feel more equipped to thoroughly interview a client and assess
his/her functioning.

1

2

3

4

6.

I will be able to write a comprehensive medical summary to be
submitted for disability determination.

1

2

3

4

7.

Overall, I am satisfied with the information provided during the
training program?

1

2

3

4

II. Questions about the Online Elements of Course
8.

This site was easy to navigate

1

2

3

4

9.

It was easy to download and access the video

1

2

3

4

10. The slides and graphics conveyed the material clearly

1

2

3

4

11. Information was well organized and flowed easily

1

2

3

4

12. The voiceover kept my attention

1

2

3

4

13. There were sufficient opportunities to practice applying the
information

1

2

3

14. The course provided helpful handouts and links to additional
information

1

2

3

15. There was a good variety of learning methods: listening, reading,
video, activities

1

2

3

16. It is likely that I will return to this website for a refresher or
additional information

1

2

3

J-1

4
4
4
4

OMB No. 0930-XXXX
Expiration Date XX/XX/XXXX

17. I think I will need to attend in-person SOAR training to further
develop my skills to submit SSI/SSDI applications

1

2

18. How long did it take for the website to load?
Less than 1 minutes

1-5 minutes

More than 5 minutes

19. Is there anything else you would like to tell us about the training?

J-2

3

4