Suicide Prevention Suicide Prevention Survey

Attachment 2: SAMHSA Suicide 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, 11-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? Colleague Professional Meeting Online Advertisement (e.g., Google ad, Facebook ad) Online App Store (e.g., iTunes, Google Play) Email From SAMHSA Professional Organization SAMHSA Website Social Media (e.g., Facebook, Twitter, Instagram, LinkedIn, blog) Other (please specify): ____________________
3. What is your primary professional role? Nurse Nurse Practitioner Physician’s Assistant Primary Care Physician Psychiatrist Psychologist/Therapist Substance Abuse Counselor Social Worker Other (please specify): ____________________
4. In what setting did you use this app? Clinical Setting In the Field (e.g., offsite consultation, home visit) During a Training Other (please specify): ____________________
5. Which one of the following app sections was most useful to you? Explore the SAFE-T MyCases Provider Education Sample Cases Treatment Resources 6. Which one of the following app features was most useful to you? Interactive Educational Content Quick Order Send/Email Reminders Set
	1 Not at all satisfied	2 Somewhat satisfied	3 Satisfied	4 Very satisfied	5 Completely satisfied
7. How satisfied are you with this app’s features?
8. 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
9. How likely are you to use this app again?
10. How likely are you to recommend this app to others?
11. 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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