Form Follow-Up Learning Follow-Up Learning Follow-Up Learning Event Feedback Form

OMB No. 0930-0197

Expiration Date: 03/31/2014

Attachment 2: Follow-Up Learning Event Feedback Form

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 0930-0197.  Public reporting burden for this collection of information is estimated to average 9 minutes per respondent, 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 8-1099, Rockville, Maryland, 20857.

Identify your role within your system of care community:

Advocate Child Welfare Clinical Director Cultural/Linguistic Coordinator Early Childhood Education/Special Education Evaluator/Researcher Family Member/Caregiver	Federal Government Health Juvenile Justice Lead Family Contact Mental Health National Organization Principal Investigator/Project Director	Service Provider Social Marketing/Communications Substance Abuse Technical Assistance Coordinator Youth/Young Person Youth Coordinator/Youth Engagement Specialist
Other (please specify): ________________________

1. Prior to this learning event, my content knowledge about providing culturally and linguistically competent supports and services for LGBTQI2-S children/youth was: Entry Level Intermediate Level Advanced Level

2. Since this learning event, my content knowledge about providing culturally and linguistically competent supports and services for LGBTQI2-S children/youth is: Entry Level Intermediate Level Advanced Level

Thinking about the learning event you participate in on [add date], please indicate the extent to which you agree with each item:

	Strongly Disagree	Disagree	Agree	Strongly Agree
The information presented at the learning event has helped me be more effective in my role within my community.
The strategies and tools shared at the learning event (e.g., handouts/materials/toolkit CD) have been helpful.
I have used the information provided at the learning event.
I have shared the information from the learning event with others.
Due to my participation in this learning event, I understand more about:
7a. LGBTQI2-S identity
7b. Challenges that children/youth who are LGBTQI2-S may experience
7c. Supports/services that can foster resilience among children/youth who are LGBTQI2-S
7d. How to enhance the cultural and linguistic competence of supports/services for children/youth who are LGBTQI2-S
I would like to participate in another LGBTQI2-S learning event.
I would like more information and resources on supporting children/youth who are LGBTQI2-S and their families.
I would like more information and resources on supporting children/youth who come from LGBT-headed families.

11. Please share any recommendations for future LGBTQI2-S learning events, webinars, or resources. We would welcome your feedback!

12. Are there particular LGBTQI2-S topics you would like more information about? Please share as much detail as you can.

13. Any additional comments: