Administrative_Dir Administrative_Direct Staff_Partner_ Data Sheet

OMB No. 0930-####

Expiration Date: ##/##/####

This form is to be completed prior to the semi-structured interviews.

VITEL Evaluation – Data Sheet

CSAT would like to learn more about you and your involvement in this organization/program. Please take a few minutes to answer these questions before the discussion begins. Your help in answering these questions is greatly appreciated and your answers will be held in confidence.

Grantee ID Number: _____________________________ Date: _____________________

Name: ______________________________________ Title: ________________________

Organization: ________________________________ Phone #: ____________________

Years in current position: _____________ Years in substance abuse Tx field: ________

What is you role?

Executive Project Director/Coordinator Direct Staff Partner/Collaborator

What is your gender? Male Female Transgender

What is your age? ___________ years old

Are you Hispanic or Latino? Yes No

[IF YES] What ethnic group do you consider yourself? Please answer yes or no for each of the following. You may say yes to more than one.

Central American Yes No

Cuban Yes No

Dominican Yes No

Mexican Yes No

Puerto Rican Yes No

South American Yes No

Other Yes No

(If Yes, Specify) __________________________________

What is your race? Please answer yes or no for each of the following. You may check all that apply.

American Indian / Yes No Alaska Native

Asian Yes No

Black / African American Yes No

Native Hawaiian / Yes No

Other Pacific Islander

White Yes No

Education (Highest Completed):

Some High School Some Vocational/technical training

High School Diploma/GED Vocational/technical certificate or diploma

Associate’s Degree Bachelor’s Degree (e.g., BS, BA)

Other (please specify) _____________________

Notice to Respondents

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-xxxx. Public reporting burden for this collection of information is estimated to average 10 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.