Service Provider Feedback Form

Project #

OMB NO. 0930-XXXX

Expiration Date 01/31/2012

Service Provider Feedback Form

Today’s Date (mm/dd/yyyy)

We are asking that you complete this brief form so that program administrators can learn about your opinions and experiences as an outreach worker, crisis counselor, team leader, or supervisor. Do not put your name on this survey. We want you to feel completely free to express your opinion. Thank you for your participation!
The first set of questions is about Crisis Counseling Assistance and Training Program (CCP) training. First, please indicate whether you have had each type of training. Then, for each training you have completed, please rate the usefulness of the training in preparing you to do your job, using a scale of 1 to 5, where 1 is not at all useful, 2 is slightly useful, 3 is moderately useful, 4 is very useful, and 5 is extremely useful.
Type of training	Have you had this training?			If YES, please rate the usefulness of this training.
	NO	YES		Not at All Useful (1)	Slightly Useful (2)	Moderately Useful (3)	Very Useful (4)	Extremely Useful (5)
Core Content Training
Transition to Regular Services Program (RSP) Training	NO	YES		(1)	(2)	(3)	(4)	(5)
Midprogram Training	NO	YES		(1)	(2)	(3)	(4)	(5)
Disaster Anniversary Training	NO	YES		(1)	(2)	(3)	(4)	(5)
RSP Phasedown Training	NO	YES		(1)	(2)	(3)	(4)	(5)
Training on how to complete the CCP evaluation tools (e.g., logs, Weekly Tally Sheet)	NO	YES		(1)	(2)	(3)	(4)	(5)
Other crisis counseling trainings offered by the State or your agency (e.g., self-care, Skills for Psychological Recovery)	NO	YES		(1)	(2)	(3)	(4)	(5)

Using a scale of 1 to 5, where 1 is extremely poor, 2 is poor, 3 is fair, 4 is good, and 5 is excellent, please rate each item below. These items relate to other things that can influence your work, such as supervision and support.
				Extremely Poor (1)	Poor (2)	Fair (3)	Good (4)	Excellent (5)
Quality of the supervision provided to you
Opportunities to interact with other staff in supportive ways				(1)	(2)	(3)	(4)	(5)
Support and training provided to help you avoid compassion fatigue or to cope with the stress of listening to and helping others				(1)	(2)	(3)	(4)	(5)
Opportunities for professional and personal growth				(1)	(2)	(3)	(4)	(5)
Appropriateness of the workload (i.e., neither too much nor too little)				(1)	(2)	(3)	(4)	(5)

PLEASE ALSO ANSWER QUESTIONS ON THE BACK.

Adequacy of the resources and tools you had available to do your job	(1)	(2)	(3)	(4)	(5)
How well you understood how your job fit into the bigger picture of your community’s response to the disaster	(1)	(2)	(3)	(4)	(5)
How well data from the evaluation were shared with crisis counseling teams or used to inform their work	(1)	(2)	(3)	(4)	(5)
How well you believe the types of services provided by the project matched the types of need present in the community	(1)	(2)	(3)	(4)	(5)
The overall quality of services provided by the project	(1)	(2)	(3)	(4)	(5)
How likely you would be to recommend this project to a friend or family member if he or she had the need	(1)	(2)	(3)	(4)	(5)
For the questions below, please share your reactions (feelings, emotions, and thoughts) about the disaster, considering your reactions in THE PAST MONTH. Using a scale of 1 to 5, where 1 is not at all, 2 is a little bit, 3 is somewhat, 4 is a quite a bit, and 5 is very much, in the past month to what extent . . .
	Not at All	A Little Bit	Somewhat	Quite a Bit	Very Much
Have you had difficulty handling other stressful events or situations due to your crisis counseling work or your reactions to it?	(1)	(2)	(3)	(4)	(5)
Has the crisis counseling work or your reaction to it interfered with how well you take care of your physical health (e.g., eating poorly, not getting enough rest, smoking more, drinking more)?	(1)	(2)	(3)	(4)	(5)
Has the crisis counseling work or your reaction to it interfered with your ability to work or carry out your other daily activities, such as housework or schoolwork?	(1)	(2)	(3)	(4)	(5)
Has your crisis counseling work or your reaction to it affected your relationships with your family or friends or interfered with your social, recreational, or community activities?	(1)	(2)	(3)	(4)	(5)
Have you been distressed or bothered about your reactions?	(1)	(2)	(3)	(4)	(5)
If you would like to speak with a counselor about your reactions or if you have concerns about your answers to these questions, please call xxx-xxx-xxxx.

These final questions will help us to describe the total group of people who completed this survey.
How many hours of crisis counseling program work do you do in a typical week?
	Less than 20 hours		20–29 hours		30–39 hours			40 or more hours
How many months have you worked with the crisis counseling program? (If less than 1 month, please enter 0.)

PLEASE CONTINUE ON THE NEXT PAGE.

Do you supervise the work of other crisis counselors?		No		Yes
In what county or parish do you commonly work?

What is your sex?

Male

Female

In what year were you born?

What is the highest level of education you have completed or degree you have received?
	No high school			High school, but no diploma or GED				GED or other high school equivalency
	High school diploma			Some college, but no degree				Associate’s degree (e.g., A.A., A.S.)
	Bachelor’s degree			Graduate or professional degree (e.g., M.A., Ph.D., M.D., J.D.)
Are you Hispanic/Latino?			No			Yes

Which of the following best describes your race? (Please select all that apply.)
	Asian or Pacific Islander		American Indian or Alaska Native		Black or African American
	White or Caucasian		Native Hawaiian

Do you have any comments you would like to share? If so, please use the box below.

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 Office of Management and Budget (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 15 minutes per participant 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 7-1044, Rockville, MD 20857.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Administrator
File Modified	0000-00-00
File Created	2021-01-31