Attachment E_Evalu Attachment E_Evaluation

OMB No. 0930-xxxx

Expiration Date xx/xx/xxxx

Dissemination Evaluation Survey – Packets

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, 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, One Choke Cherry Road, Room 8-1099, Rockville, Maryland 20857.

Increased efforts are being made by the U.S. Government to improve the dissemination and implementation of evidence-based practices into routine health care. This survey is being conducted as part of a larger study funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) to examine factors that influence an organization’s decision to adopt evidence-based practices.  

One week ago you received an informational packet related to the implementation of Motivational Interviewing (MI). We are interested in hearing from you regarding the quality, presentation and helpfulness of this packet. Your participation in this survey is voluntary. There are no right or wrong answers to the questions. We are interested in what you think. If you are uncomfortable answering a question, you may skip that question. Your responses will be protected under the Federal Privacy Act. Your name and address will be kept in a separate file from your survey responses as a procedural safeguard. No one from your organization will see your answers.  

This survey will take approximately 5-10 minutes to complete. Please use the next and back buttons at the bottom of each page to advance forward or go back. Every time you hit the next or back button, your progress is saved automatically. You do not have to complete your survey in one sitting. You can stop your survey and return to complete it at a later time by following the survey link. At the end of the survey you will be asked to submit it. Once it has been submitted, you cannot make any further changes.

I received a Motivational Interviewing (MI) packet

• True

• False

Skip Pattern Programmed Here

How did you receive the MI packet? [CHECK ALL THAT APPLY]

• Hardcopy from the mail

• Electronic copy from email

• Director/supervisor

• Coworker

• Other (please specify) ____________________

How much of the MI packet have you read?

• None

• About Half

• All

I have made plans to use the information in the MI packet

• True

• False

I have talked to others at my program about the information in the MI packet

• True

• False

I have shared the MI packet with others at my program

• True

• False

Skip Pattern Programmed Here

If you have shared the MI packet with others in your program, identify the role(s) of such person or persons within the program. 

I have obtained or tried to obtain resources on the implementation of MI

• True

• False

Skip Pattern Programmed Here

What resources on the implementation of MI did you obtain (or try to obtain)?

I have received technical assistance related to MI in addition to the packet

• True

• False

How would you describe the content of the MI packet?

• Too Technical

• About Right

• Too Simple

• No Opinion

How would you describe the format of the MI packet?

• Very User-Friendly

• Somewhat User-Friendly

• Not User-Friendly

• No Opinion

Overall, how helpful was the MI packet in helping you to decide whether to implement MI?

• Very helpful

• Somewhat helpful

• Not helpful

• No opinion

What did you like most about the MI packet?

What did you like least about the MI packet?

What suggestions do you have to improve the MI packet?

You have reached the end of the survey.   If you wish to go back to review and/or change your responses to one or more items, please do so now using the back button below. If you are ready to submit your responses, please click the next button below to advance to the next page. Once you submit your responses, you will not be able to return to the survey.  Thank you for your time and participation.

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