Form Follow-Up Survey Follow-Up Survey Follow-Up Survey

Form Approved

OMB No. 0930-0197

Expiration Date: 03/31/2014

Substance Abuse and Mental Health Services Administration (SAMHSA)

Center for Substance Abuse Prevention (CSAP)

Prevention Fellowship Program (PFP)

ALUMNI FOLLOW-UP SURVEY

Notice to Respondents

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 3 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 2-1057, Rockville, Maryland, 20857.

We would like to know about your activities following your participation in CSAP’s Prevention Fellowship Program. Please take a moment to respond to the following questions. Your feedback will help us ensure that the program is achieving its intended purposes.

This survey is voluntary. If you choose to take it, you may skip any question you don’t want to answer. This survey asks about your career activities and about your opinions regarding the program’s impacts. Your answers to these questions will be protected. That means no one will connect your answers with your name or other identifying information. To help us keep your answers confidential, please do not write your name on this survey. The information in this survey will be used to learn more about the effectiveness of this program.

1. Why did you exit the program? ( Check all that apply)

• ₁ Graduated from the program

• ₂ Accepted a job offer

• ₃ Enrolled in a graduate degree/continuing education program

• ₄ No longer interested in the program

• ₅ Other (please specify) _______________________________________

2. Did you successfully complete the International Certification & Reciprocity Consortium (IC&RC) exam for prevention certification?

• ₁Passed the IC&RC exam

• ₂Did not pass the IC&RC exam and do not plan to re-take the exam

• ₃Did not pass the IC&RC exam and plan to re-take the exam in the future

• ₄Took the IC&RC exam, results pending

• ₅Did not take the IC&RC exam, but plan to take the exam in the future

• ₆Did not take the IC&RC exam, and do not plan to take the exam in the future

3. What is your current position or title?

4. What is your current professional field? (Check all that apply)

• ₁Prevention

• ₂Substance abuse

• ₃Other public health (please specify):

• ₄Other health-related sector (please specify):

• ₅Other non-health-related sector (please specify):

5. Have you used the knowledge and skills you gained during your participation in the PFP program to train other individuals in your community, work place, or school?

• ₀No  ₁Yes

5a. If yes, how many individuals?

 ₁1-5  ₂6-10  ₃10-15  ₄16-20  ₅More than 20

6. Please rate the degree to which you agree with the following statement:

As a result of my participation in the PFP, my opportunities for jobs within the prevention field have increased.

 Strongly agree  Agree  Neutral  Disagree  Strongly Disagree

7. What were the most beneficial aspects of your experience with the Prevention Fellowship Program?
   (Please be specific)

Thank you for completing the ALUMNI FOLLOW-UP SURVEY. We appreciate your feedback.