Form Participant_Feedba Participant_Feedback_Form

OMB NO. 0930-xxxx

Expiration Date xx/xx/xxxx

Project #

Participant Feedback Survey

Today’s Date (mm/dd/yyyy)

This anonymous form will help community leaders learn about needs in our community, and about how well the crisis counselors/outreach workers are meeting these needs. Please do not put your name on this form. If you filled out a form like this in the past week, please do not fill out this one. We thank you very much for your time!
How good of a job did the counselor or outreach worker do . . .	Extremely poor (1)	Poor (2)	Fair (3)	Good (4)	Excellent (5)
Treating you with respect?
Respecting your culture, race, ethnicity, or religion?	(1)	(2)	(3)	(4)	(5)
Making you feel that asking for help is okay?	(1)	(2)	(3)	(4)	(5)
Making you feel that you can help yourself and your family?	(1)	(2)	(3)	(4)	(5)
Keeping things you said private?	(1)	(2)	(3)	(4)	(5)

Please indicate below which program services you have used. If you have used the service, please indicate whether or not it was helpful to you.

Have you used this service?

Was this service helpful?

Yes

No

Yes

No

One-to-one interaction (with counselor/outreach worker)

Public education presentation

Yes

No

Yes

No

Group counseling/support group

Yes

No

Yes

No

Handouts/materials

Yes

No

Yes

No

Internet sites (Crisis Counseling Assistance and Training Program [CCP] website, Facebook, etc.)

Yes

No

Yes

No

Other (please specify):_______________________________________________

Yes

No

Yes

No

Referral resources

Yes

No

Yes

No

PLEASE ALSO ANSWER QUESTIONS ON THE NEXT PAGE.

If you have used referral resources, which types(s) did you utilize?

Substance use

Community services (e.g., Federal Emergency Management Agency, loans, housing, employment, social services)

Mental health

Resources for those with disabilities or other access or functional needs

CCP services

Other referral type (Please specify type:_____________________)

Extremely poor

Poor

Fair

Good

Excellent

How good of a job did this program do with . . .

(1)

(2)

(3)

(4)

(5)

Helping you to know that your feelings after the disaster were the same as many other people’s feelings?

Helping you to find ways to take care of yourself, like eating right and getting enough sleep?

(1)

(2)

(3)

(4)

(5)

Helping you to stay active in things like hobbies, sports, church, or volunteer work?

(1)

(2)

(3)

(4)

(5)

In general . . .

Extremely poor

Poor

Fair

Good

Excellent

How good was the information you got on how people feel after disasters?

(1)

(2)

(3)

(4)

(5)

How good of an idea is it to tell a friend who was upset by the disaster to see this counselor or outreach worker?

(1)

(2)

(3)

(4)

(5)

Not at all useful (1)

Slightly useful (2)

Moderately useful (3)

Very useful (4)

Extremely useful (5)

How useful was this program in helping return things in your life back to the way they were before the disaster?

Overall, how useful was this program to you?

People experience disasters in a variety of ways. Below is a list of experiences you may have had. Please select all that apply to you.

My family member is missing or dead.

My life or that of someone in my household was threatened.

My friend is missing or dead.

I or a member of my household witnessed death/injury.

My pet is missing or dead.

I or a member of my household assisted with rescue/recovery.

My home is damaged or destroyed.

I am or a member of my household is unemployed because of this disaster.

I had major property loss, such as car/vehicle loss.

I was evacuated quickly with no time to prepare.

I had other financial loss.

I had prolonged separation from family.

PLEASE CONTINUE ON NEXT PAGE.

I or a member of my household was injured or physically harmed.

I was displaced from my home for 1 week or longer.

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 quite a bit, and 5 is very much, in the past month to what extent have you . . .

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

Been bothered by bad memories, nightmares, or reminders of what happened?

Tried NOT to think or talk about what happened or to do things that remind you of what happened?

(1)

(2)

(3)

(4)

(5)

Been bothered by poor sleep, poor concentration, feeling jumpy or angry, or being scared that something else bad will happen?

(1)

(2)

(3)

(4)

(5)

Been down or depressed?

(1)

(2)

(3)

(4)

(5)

Found other stressful things harder to deal with because of what happened?

(1)

(2)

(3)

(4)

(5)

Had trouble taking care of your health (e.g., eating poorly, not getting enough rest, smoking more, drinking more)?

(1)

(2)

(3)

(4)

(5)

Had difficulty getting along or having fun with family and friends?

(1)

(2)

(3)

(4)

(5)

Needed help from a counselor to deal with your reactions to the disaster?

(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.

Comparing your emotional and mental well-being before the disaster to now, do you feel better, worse, or about the same?

Feel better now

Feel about the same

Feel worse now

Comparing how well you take care of your health before the disaster to now, do you take care of your health better, worse, or about the same?

Take care of your health better now

Take care of your health about the same now

Take care of your health worse now

Comparing how well you work (including a job, schoolwork, and housework) before the disaster to now, do you have less trouble working, more trouble working, or about the same amount?

Have less trouble working now

Have about the same amount of trouble working now

Have more trouble working now

Comparing how active you were in things like hobbies, sports, church, or volunteer work before the disaster to now, are you more active, less active, or about the same?

More active now

About the same

Less active now

PLEASE ALSO ANSWER QUESTIONS ON THE BACK.

The final questions will help us to describe the total group of people who completed the form.
How do you identify yourself?		Male		Female
In what year were your born? _____________

What is the highest level of education you have completed or degree you have received?
	0–6 years		Some college
	7–11 years		College graduate or more
	12 years (high school diploma or GED)

In what county or parish do you currently live? _______________________________

Are you Hispanic/Latino?

Yes

No

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

Other (Please specify):_____________________________________________

What is your preferred language?

English

Spanish

Other (please specify):______________

If you have a disability, or other access or functional need, please indicate the type (select all that apply).
Physical (mobility, visual, hearing, etc.)	Intellectual/Cognitive (learning disability, mental retardation, etc.)	Mental Health/Substance Use (psychiatric issue, substance dependence, etc.)

Thank you for taking time to complete this form!

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 0930-0270. 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.