Form NRC Online Feedbac NRC Online Feedbac NRC Online Feedback Form

Attachment 1: NRC Online Feedback Form

OMB No. 0930-0197

Expiration Date: 1/31/2017

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 17 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 15E57-B, Rockville, Maryland, 20857.

T/TA online feedback protocols and instruments

Online Learning Events (OLEs) and Fieldwide Webinars (Webinars): The online feedback form is customized and used to collect feedback from people who participate in any SS/HS or Project LAUNCH Online Learning Event (OLE), and fieldwide webinars for professionals in the field unaffiliated with either grant program. Immediately after completion of each OLE or webinar, the feedback form is provided to all participants should they be interested in providing feedback to the NRC. The feedback forms are administered through Adobe Connect (for OLEs) and SurveyMonkey (for webinars). The results are then analyzed and described in a summary report by NRC staff.

NRC [insert grant program name] Online Feedback Form

Thank you for participating in today’s Online Learning Event [insert name of online learning event]. [If a webinar, insert name of webinar title and also revise “online learning event” throughout to “webinar”]. To continue to improve the quality of our online learning events, we ask that you please tell us how much you agree or disagree with the following statements and answer the following questions regarding your experience with this event. Your participation is completely voluntary and confidential.

1. Are you a [insert name of grant program] grantee?

• Yes

• No

1a. If No, please state the name of your agency or affiliation in the space below, then skip to Question 3.

2. Which of the following best describes your role(s) on the [insert name of grant program]? (Check all that apply.)

[use these roles for SS/HS]:

• State project coordinator/staff

• School district/community project staff

• Evaluator/researcher

• Other

[use these roles for Project LAUNCH]:

• Young Child Wellness Coordinator

• Young Child Wellness Expert

• Young Child Wellness Partner

• Project Director/Principal Investigator

• Expansion Grantee State Lead

• Expansion Grantee Local Lead

• Expansion Site Local Stakeholder

• Evaluator/researcher

• Other

2a. If Other, please write the name of your role in the space below.

2b. [For Project LAUNCH]:

Please specify your cohort.

• Cohort 4

• Cohort 5

• Cohort 6

• Expansion grantee

• Other

[Note: for webinars, use these as the first two questions and revise wording throughout this feedback from “online learning event” to “webinar”.]:

1. Are you a current or former Safe Schools/Healthy Students (SS/HS) or Project LAUNCH grantee?

□ Yes (select one)

□ SS/HS

□ Project LAUNCH

□ No

1a. If no, which of the following best describes your professional affiliation? (Check all the boxes that apply)

• Education (k-12) professional

• Special education professional

• Post-secondary/Higher education professional

• Early childhood (ages 0 – 5 years) professional

• Childcare professional

• Child welfare professional

• School health (nurse, clinic) professional

• Primary care (doctor, nurse, nurse practitioner)

• Mental health (psychologist, counselor, therapist, social worker) professional

• Juvenile justice/law enforcement professional

• Substance abuse (counselor, prevention) professional

• Government (federal, state, or local) employee

• National association member/staff

• Community-based/nonprofit organization professional

• Evaluator/researcher

• Family member/caregiver

• Other

1b. If other, please write your professional affiliation in the space below.

3. Please select the total number of people (including yourself) who participated in this online learning event with you (together from your desk, conference room, etc.):

• 1 person (I watched this online event alone)

• 2 people (1 person was with me)

• 3 people (2 people were with me)

• 4 people (3 people were with me)

• 5 people (4 people were with me)

• 6 people or more (5 people or more were with me)

If more than one person participated in this online learning event, please try to come to consensus on your answers to the following questions:

4. Please rate your knowledge of the topic [insert name of online learning event] prior to attending this event.

□ Not knowledgeable

□ Slightly knowledgeable

□ Moderately knowledgeable

□ Very knowledgeable

5. Please rate your knowledge of the topic [insert name of online learning event] after attending this event.

□ Not knowledgeable

□ Slightly knowledgeable

□ Moderately knowledgeable

□ Very knowledgeable

6. This online learning event improved my understanding of [insert objective #1 of online learning event]

• Strongly Disagree

• Disagree

• Agree

• Strongly Agree

7. This online learning event [insert objective #2 of online learning event].

• Strongly Disagree

• Disagree

• Agree

• Strongly Agree

8. This online learning event improved my understanding of [insert objective #3 of online learning event].

• Strongly Disagree

• Disagree

• Agree

• Strongly Agree

9. This online learning event improved my understanding of [insert objective #4 of online learning event].

• Strongly Disagree

• Disagree

• Agree

• Strongly Agree

10. The online learning event delivered information in a clear manner and was easy to follow.

• Strongly Disagree

• Disagree

• Agree

• Strongly Agree

11. I plan to share information from this online learning event with others in my organization.

• Strongly Disagree

• Disagree

• Agree

• Strongly Agree

12. I am motivated to apply information provided from this online learning event in my organization’s communication efforts.

• Strongly Disagree

• Disagree

• Agree

• Strongly Agree

13. To what extent has this online learning event improved your knowledge of promoting mental health and/or prevention?

• Not at all

• Slightly

• Moderately

• A great deal

14. Overall, how satisfied were you with this online learning event?

• Very dissatisfied

• Somewhat dissatisfied

• Somewhat satisfied

• Very satisfied

15. Please provide at least one example of what you have learned from this online learning event that you can apply to your work.

16. Please provide any additional comments about how to improve the online learning event such as suggestions for topics for future learning events that will help support your work, or any other comments:

COMMENTS:

Attachment 1 6