Form CMS

OMB No. 0930-XXXX

Expiration Date XX/XX/XXXX

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 15 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.

ATTACHMENT 3: Collaborative Member Survey

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CMS1INTRO1

Thank you for taking the time to complete the Advisory Team Collaboration Member Survey. You are being asked to complete this survey because you have been identified as a member of one or more advisory or other interagency groups or “teams” for your state or one of its local partners’ Now is the Time Healthy Transitions grant programs, specifically, the [NAME AND/OR ALTERNATE NAMES USED BY GRANTEE TO REFER TO THEIR TEAM].

Healthy Transitions program supports states and local communities in developing outreach and services for transition-age (16-25 year-old) youth and young adult with or at risk of mental health conditions, the focus of the work of the [NAME AND/OR ALTERNATE NAMES USED BY GRANTEE TO REFER TO THEIR NITT-HT PROJECT] team.

This survey is designed to help the National Evaluation for Now is the Time-Healthy Transitions better understand how teams such as yours work together, specifically with regards to their impact, leadership, functioning, vision, managing of conflict, and satisfaction. Even if you are not very active currently, your perspective is still thought to be important to understanding your team. By taking the time to fill out this survey, you provide valuable information that can be used to inform the work of your team. In turn, findings from your team will be used to help inform the work of similar advisory or interagency groups in the future through communication of evaluation findings to SAMHSA and stakeholders for the NITT-HT program nationally.

Please respond to this survey regarding your perceptions and experience with your team as a whole rather than your perceptions of only one subcommittee or work group. In this survey, the use of the term ‘team’ refers to the [NAME AND/OR ALTERNATE NAMES USED BY GRANTEE TO REFER TO THEIR TEAM].

CMS1INTRO2

You were selected to complete this survey because of your participation in the [CMS1ADVTEAM]. By taking the time to complete this survey, you are providing valuable information that will inform advisory groups and organizations working with youth and young adults.

We anticipate this survey will take 15 minutes to complete. If you start and are unable to complete the survey, you can return to complete it at a later time using the same link, ID and password. All answers will be automatically saved and the survey will continue where you left off. When you have completed all questions, press “Submit” on the final screen.

Thank you again for your participation and support in the NITT-HT project.

CMS1GRNTID

Please select from the drop down menu your grantee state and ID.

[DROP DOWN BOX]

AK – SM061910

CT – SM061971

DC – SM061903

DE – SM061931

FL – SM061898

KY – SM061899

MA – SM061850

MD – SM061917

ME – SM061843

NM – SM061905

NY – SM061900

OK – SM061842

PA – SM061915

RI – SM061885

TN – SM061867

UT – SM061974

WI – SM061916

CMS1ADVTEAM

Please select from the drop down menu the Advisory Team for which you are a member.

[PRELOAD VARIABLE]

CMS1OTHRTEAM

UMMS ADDED ITEM

Do you participate on any other teams related to [NAME AND/OR ALTERNATE NAMES USED BY GRANTEE TO REFER TO THEIR NITT-HT PROJECT]? If so, please identify these teams

[TEXT BOX]

CMS1RROLE

Please indicate your role as a participant in the [CMS1ADVTEAM]. Are you a…

1 Provider (someone whose primary role is to provide assessment, intake, outreach, or services to youth and young adults).

2 Administrator or supervisor

3 Youth/Young Adult currently or formerly receiving services

4 Family member of a youth/young adult currently or formerly receiving services

5 Some other role

[IF CMS1RROLE=5; ELSE SKIP TO ]

CMS1RROLEO

Please specify your role as a participant in the [CMS1ADVTEAM].

[TEXT BOX]

CMS1NOMTGS

How many meetings of this team have you attended?

1 – one

2 – two

3 – three

4 – four

5 – five

6 – six

7 – seven

8 – eight

9 – nine

10 – ten or more.

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ADVISORY TEAM IMPACT

CMS1IMPCTINTRO

The next set of statements concern potential impacts the [CMS1ADVTEAM] may or may not have had on your organization’s work in the field. By “your organization’s work in the field” we mean work within the system that serves youth and young adults that are the focus of the work of [CMS1ADVTEAM], or the population of focus for the Now is the Time-Healthy Transitions grant program, “transition-age” youth and young adults, ages 16-25 with or at risk for mental health conditions. This work can include, but is not limited to, providing services, being a leader or administrator in a youth-serving organization, mentoring or advising youth and young adults or their families, being young adult or family member advocating for other young adults and family members, etc. If only a part of the work of your organization/agency concerns youth and young adults served by [CMS1ADVTEAM], please respond on behalf of the particular unit, office, or work group.

NOTE: If you are participating in the team as a youth or family advocate and belong to an advocacy organization (e.g., YouthMOVE, Federation of Families) think about any impacts the [CMS1ADVTEAM] may have had on your advocacy organization. If you do not belong to such an organization, think about the impact the [CMS1ADVTEAM] may have had on young adults and families in your community.

Going forward we will refer to the [CMS1ADVTEAM] as “the team”.

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For each statement below, please indicate the extent to which it represents the impact the team has had on your organization’s work in the field serving youth and young adults with mental health conditions or at risk of mental health conditions.

Participation in the [CMS1ADVTEAM] has led to…

	Not at all (1)	A little (2)	To some extent (3)	Quite a bit (4)	A great deal (5)	Not applicable to my role (9 )
Increased knowledge about what services and resources available in the community for youth and young adults [CMS1IMPCT1]
An improvement in our ability to diagnose the root of a problem in order to come up with more effective solutions [CMS1IMPCT2]
Increased knowledge about how the system as a whole works and how organizations and agencies affect one another [CMS1IMPCT3]
Increased utilization of our expertise or services for youth and young adults [CMS1IMPCT4]
Opportunity to have a greater impact than we could on our own [CMS1IMPCT5]
Increased understanding of the needs and preferences of youth and young adults receiving services [CMS1IMPCT6]
Increased knowledge about how to best interact with other organizations in order to accomplish our objectives [CMS1IMPCT7]
Increased the level of respect and credibility we have with other agencies and organizations [CMS1IMPCT8]
Increased how responsive other organizations and agencies are to your questions or concerns [CMS1IMPCT9]
Increased communication with others in the field [CMS1IMPCT10]
Increased how supportive other organizations and agencies are of your organization [CMS1IMPCT11]

CMS1IMPCT12

What is the most positive aspect of your participation in the team?

[TEXT BOX]

CMS1IMPCT13

Please provide examples of specific projects that you have either undertaken with other team members since joining or that were somehow facilitated through your work of the group.

[TEXT BOX]

[PROGRAMMER NOTE: CHECK BOX OPTION]

CMS1IMPCT14

__ I have not participated in any Advisory Team projects.

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NEGATIVE ORGANIZATIONAL IMPACTS

CMS1NEGIMPCT

Next we'd like to know if involvement on the team has had any negative impacts.

Have you or your organization been negatively impacted in any way as a result of being involved with the team? NOTE: “negative impact” could include unproductive use of your time.

1 Yes

2 No

[IF CMS1NEGIMPCT=1 GET CMS1NEGIMPCT1; ELSE SKIP TO CMS1NEGIMPCT2]

CMS1NEGIMPCT1

Please describe these negative impact(s).

[TEXT BOX]

CMS1NEGIMPCT2

How have the costs associated with being involved with the team compared to the benefits? Costs and benefits may be in terms of money, effort, time, or in other forms.

1 Costs have significantly outweighed the benefits

2 Costs have somewhat outweighed the benefits

3 Costs and benefits have been equal

4 Benefits have somewhat outweighed the costs

5 Benefits have significantly outweighed the costs

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TEAM LEADERSHIP

CMS1LEADER

Advisory teams often have one or more people who take on leadership roles at different times, either formally or informally. Please indicate to what extent you agree or disagree with the following statements about the leaders of your team.

The leaders of my team…

	Strongly disagree (1)	Disagree (2)	Somewhat disagree (3)	Somewhat agree (4)	Agree (5)	Strongly agree (6)
Inspire people to do more than what is expected of them [CMS1LEADER1]
Inspire us to want to do better [CMS1LEADER2]
Take time to find out about the concerns and issues of my organization [CMS1LEADER3]
Are adept at fostering respect, trust, inclusiveness, and openness in the team [CMS1LEADER4]
Are skilled at integrating diverse viewpoints, negotiating, problem solving and resolving conflicts among team members [CMS1LEADER5]
Are skilled at helping youth and young adults in services to have a voice in and influence team decisions. [CMS1LEADER6]
Are skilled at helping family members of youth to have a voice in and influence team decisions. [CMS1LEADER7]
Help us to stay focused on why we are here [CMS1LEADER8]
Plan meetings effectively and efficiently [CMS1LEADER9]

CMS1LEADER10

What do you think team leader(s) could do differently and how would that make a difference?

[TEXT BOX]

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CMS1TEAM

Please indicate to what extent you agree or disagree with the following statements about how your team makes decisions.

	Strongly disagree (1)	Disagree (2)	Somewhat disagree (3)	Somewhat agree (4)	Agree (5)	Strongly agree (6)
When making decisions, team members are responsive to all of the viewpoints represented on the team [CMS1TEAM1]
Team decisions are dominated by a few members [CMS1TEAM2]
The team does not move forward on a decision until all input is heard [CMS1TEAM3]
The involvement of different kinds of members has led to new and better ways of thinking about how the team can achieve its goals. [CMS1TEAM4]
Team members are especially attentive to viewpoints of youth and young adults in services and weigh these heavily in decisions. [CMS1TEAM5]
Team members are especially responsive to viewpoints of family members of youth and young adults in services and weigh these heavily in decisions. [CMS1TEAM6]
My input influences the decisions the Team makes [CMS1TEAM7]

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Please indicate to what extent you agree or disagree with the following statements about how your team makes decisions overall.

	Strongly disagree (1)	Disagree (2)	Somewhat disagree (3)	Somewhat agree (4)	Agree (5)	Strongly agree (6)
The team often reviews its goals and objectives [CMS1TEAM8]
The methods used by the team to accomplish its goals are often discussed [CMS1TEAM9]
We regularly discuss whether the team members are working effectively together [CMS1TEAM10]
In this team, we modify our goals and objectives in light of changing circumstances [CMS1TEAM11]
Team strategies are rarely changed [CMS1TEAM12]
The way decisions are made in this team is rarely altered [CMS1TEAM13]

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TEAM VISION

The following questions are about your team’s vision – what the team would like to see happen in the community in the future to benefit youth and young adults with or at risk of mental health conditions.

CMS1TEAM14

Members of the team have a common vision for how service systems for youth and young adults should be improved through the Healthy Transitions Initiative.

1 Not at all

2 A little

3 Some

4 Quite a bit

5 A great deal

6 Entirely

CMS1TEAM15

Members of the team agree on the specific ways or processes to put in place for achieving improvements in service systems for youth and young adults.

1 Not at all

2 A little

3 Some

4 Quite a bit

5 A great deal

6 Entirely

CMS1TEAM16

All teams engage in some degree of discussion and conflict when making decisions. To what extent are personality clashes present in your team?

1 Not at all

2 A little

3 Some

4 Quite a bit

5 A great deal

6 Entirely

CMS1TEAM17

How often do people on the team disagree about the work being done?

1 Not at all

2 A little

3 Some

4 Quite a bit

5 A great deal

6 Entirely

CMS1TEAM18

How often do people in your team disagree about ideas concerning how to improve the community’s response to youth and young adults?

1 Not at all

2 A little

3 Some

4 Quite a bit

5 A great deal

6 Entirely

CMS1TEAM19

How much do “politics” hinder the effectiveness of the team?

1 Not at all

2 A little

3 Some

4 Quite a bit

5 A great deal

6 Entirely

CMS1TEAM20

Overall, when important decisions are discussed among the team, would you say there is…

1 A great deal of disagreement, which improves decision making

2 Some disagreement, which improves decision making

3 Little to no disagreement

4 Some disagreement, which impedes decision making

5 A great deal of disagreement, which impedes decision making

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MEMBER SATISFACTION

For each item below, please indicate how satisfied or dissatisfied you are overall with the…

	Very dissatisfied (1)	Dissatisfied (2)	Neither satisfied nor dissatisfied (3)	Satisfied (4)	Very Satisfied (5)
Team and your role as a team member [CMS1SATISF1]
Objectives of the team? [CMS1SATISF2]
Plans (e.g., action plans, work plans) produced by the team? [CMS1SATISF3]
How much the team follows suggestions of youth and young adults receiving services? [CMS1SATISF4]
How much the team follows the suggestions of family members? [CMS1SATISF5]

CMS1SATISF6

What does this team do well?

[TEXT BOX]

CMS1SATISF7

How do you think the team could improve overall?

[TEXT BOX]

FINAL SCREEN

Those are all the questions we have for you. Thank you for taking the time to complete the Healthy Transitions Collaborative Member Survey. Your input will assist in the national evaluation of the Healthy Transitions program and grantee services for youth and young adults in transition.

Attachment 5: Collaborative Member Survey 8