Form Contractor Attachm Contractor Attachm Contractor Attachments

Attachment 1: Initial Invitation

Technical Assistance (TA) Site Visit Follow-Up Questionnaire

OMB No. 0930-0197

Expiration Date: 3/31/14

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 10 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.

Host Site: ______________________________________

Visited by:______________________________________

Date: __________________________________________

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree	N/A
1. The planning process for the site visit was effective.						
2. The TA visit team addressed the needs of our jurisdiction.						
3. The technical assistance supported our jurisdiction in the development of a strategic plan.						
4. The TA visit team conducted the visit in a culturally and linguistically competent manner.						
5. The TA visit team conducted the visit in a family-friendly manner.						
6. The TA visit team conducted the visit in a youth-friendly manner.						
7. Please list any recommendations for improvement of the TA visit.
8. What were the positive aspects of the TA visit?

Attachment 2: Initial Invitation

Technical Assistance Product Review Survey

OMB No. 0930-0197 Expiration Date: 3/31/14

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 10 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.

1. Do you work within a currently funded system of care community?

1. No  b) Yes  c) Unsure

2. To what extent have you reviewed the product?

1. Only scanned the product  (b) Reviewed parts of the product closely  c) Reviewed the full product closely

3. To what extent does the product provide information clearly?

1. Not clearly written  b) Somewhat clearly written  c) Very clearly written

4. Overall, how satisfied are you with the product’s content?

1. Not satisfied  b) Somewhat satisfied  c) Very satisfied

5. Will the product be useful to you in your community/family role?

1. No  b) Maybe  c) Yes

6. Would you recommend this product to a colleague or other community member?

1. No  b) Maybe  c) Yes

  

7. Please provide any additional feedback about this product or recommendations for other products: