Form Bulling Prevention Bulling Prevention Bulling Prevention Survey

Attachment 1: SAMHSA Bullying Prevention App: User Feedback Survey

OMB No. 0930-0197

Expiration Date: 01/31/17

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 0930-00197.  Public reporting burden for this collection of information is estimated to average fewer than 5 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.

Thank you for using this [APP NAME]! We invite you to take this short, 12-question survey. Whether or not you complete the feedback questions, it will not affect any services you receive from the Substance Abuse and Mental Health Services Administration (SAMHSA).

Click one of the options below. If you click on “Start feedback questions now,” you are giving SAMHSA permission to review your anonymous responses.

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Start feedback questions now.

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I do not want to participate.

SAMHSA Customer Satisfaction Survey

1. You are: _____Male _____Female
2. How did you hear about this app? Email from SAMHSA Family Member, Friend, Neighbor, Colleague My Child’s School, Camp, or Other Program Online Advertisement (e.g., Google ad, Facebook ad) Online App Store (e.g., iTunes, Google Play) SAMHSA Website Social Media (e.g., Facebook, Twitter, Instagram, LinkedIn, blog) Other (please specify): ____________________
3. In what role would you use this app? Parent Faith Leader Foster Parent/Guardian Grandparent or Other Family Member Guidance Counselor School Administrator Sports Coach Teacher Other Mentor (please specify): ____________________
4. Have you witnessed bullying or signs of bullying already? _____ Yes _____ No
5. Have you had the opportunity to use this app with at least one child? Yes. If Yes: 5a. How often have you used the app _____ 1 time _____ 2‒5 times _____ once a month _____ once a week _____ more than once a week 5b. With approximately how many children have you used the app? _____ 5c. What is the age range of the children with whom you have used the app? [Check all responses that apply.] _____ 5‒11 years _____ 12‒13 years _____ 14‒17 years 5d. What is the approximate percentage breakdown of boys and girls with whom you have used the app?* _____ Boys _____ Girls *Must add up to 100% No
6. Which one of the following app sections was most useful to you? About Home/Conversation Starters Learn My Kids Resources Talk
7. Which one of the following app features was most useful to you? Add reminder Share
	1 Not at all satisfied	2 Somewhat satisfied	3 Satisfied	4 Very satisfied	5 Completely satisfied
8. How satisfied are you with this app’s features?
9. How satisfied are you with this app’s “look and feel?”
	1 Not at all likely	2 Unlikely	3 Neutral	4 Likely	5 Extremely likely
10. How likely are you to use this app again?
11. How likely are you to recommend this app to others?

12. One thing I would suggest to improve this app is: ___________________________

Thank you for taking the time to offer your important feedback on this SAMHSA app!

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