Form MAT APP MAT APP MAT APP

Attachment 1: Medication-Assisted Treatment (MAT) App: User Feedback Survey

OMB No. 0930-0197

Expiration Date: 01/31/2017

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 fewer than 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, 5600 Fishers Lane, Room 15E57B Rockville, MD.

Thank you for using the [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 self-identify as: _____Male _____Female _____Other (please specify) 2. What is your age? 18-24 years old 25-34 years old 45-44 years old 55-64 years old 65-74 years old 75 years or older
3. How did you hear about this app? Colleague Professional Meeting/Professional Organization Online Advertisement (e.g., Google ad, Facebook ad) Online App Store (e.g., iTunes, Google Play) Email From SAMHSA Journal or newspaper article SAMHSA Website Social Media (e.g., Facebook, Twitter, Instagram, LinkedIn, blog) Other (please specify): ____________________
4. What is your primary professional role? Alcohol and/or other Substance Use Disorder (SUD) Counselor Dentist Doctor of Nursing Practice (DNP) Licensed Clinical Social Worker (LCSW) Medical Social Worker (MSW) Mental/Behavioral Health Therapist Nurse Nurse Practitioner Osteopath Pharmacist Physician’s Assistant Primary Care Physician Psychiatrist Psychologist Other (please specify): ____________________
5. In what setting did you use this app? Outpatient Clinical Setting Inpatient Clinical Setting In the Field (e.g., offsite consultation, home visit, street outreach site) During a Training/Clinical Consultation/Clinical Supervision Other (please specify): ____________________
	1 Not at all effective	2 Somewhat effective	3 Effective	4 Very effective	5 Not applicable
6. Was this app effective in supporting your practice of medication-assisted treatment?
	1 Strongly Agree	2 Agree	3 Neutral	4 Disagree	5 Strongly Disagree
7. This app helped me locate resources and services to better serve patients with substance use disorders (SUD).
	1 Strongly Agree	2 Agree	3 Disagree	4 Strongly Disagree	5 Not Applicable
8. This app provided me with resources and information I need to pursue becoming DATA-waived, so that I can begin treating with buprenorphine for opioid misuse.
	1 Strongly Agree	2 Agree	3 Neutral	4 Disagree	5 Strongly Disagree
9. This app was user friendly
	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. Things I would suggest to improve this app are: ___________________________

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

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