Technical.Assistan Technical.Assistance.Post.Event.Form

National Cross-Site Assessment of Addiction Technology Transfer Centers (ATTC) Network

Attachment.2-3.Technical.Assistance.Post.Event.Form 6.7.16

Staff - TA - Post Event

OMB: 0930-0216

Document [doc]
Download: doc | pdf

Form Approved

OMB NO. 0930-0216

Exp. Date 09/30/2016

See burden statement on the reverse side


Addiction Technology Transfer Center (ATTC) Network

Post-Event Form for Technical Assistance


Participants – Please Write Your Unique Personal Code Here as Follows:



First Letter of Mother’s First Name:


First Letter of Mother’s Maiden Name:




First Digit of Social Security Number:


Last Digit of Social Security Number:






Office Use Only - ATTC Event Code:









  1. How satisfied are you with the overall quality of this technical assistance?

Very

Satisfied



Satisfied




Neutral





Dissatisfied




Very Dissatisfied





  1. How satisfied are you with the quality of the staff leading the session?



  1. How satisfied are you with the quality of the technical assistance materials?



  1. Overall, how satisfied are you with your technical assistance experience?



PLEASE INDICATE YOUR AGREEMENT WITH THESE STATEMENTS ABOUT THE SESSION.

  1. The technical assistance was well organized.

Strongly

Agree




Agree





Neutral




Disagree



Strongly

Disagree





  1. The material presented in this session will be useful to me in dealing with substance abuse.



  1. The staff was knowledgeable about the subject matter.



  1. The staff was well prepared for the course.



  1. The staff was receptive to participant comments and questions.



  1. I am currently effective when working in this topic area.



  1. The technical assistance enhanced my skills in this topic area.






Please Continue to Next Page





Strongly

Agree



Agree



Neutral



Disagree



Strongly

Disagree


  1. The technical assistance was relevant to my career.


  1. I expect to use the information gained from this technical assistance.


  1. I expect this technical assistance to benefit my clients.


  1. This technical assistance was relevant to substance abuse treatment


  1. I would recommend this technical assistance to a colleague.




Very

Useful



Useful



Neutral



Useless



Not

Applicable




  1. How useful was the information you received from the instructor?


18. Your gender: Female Male Transgender


19. Are you Hispanic or Latino/a? Yes No


  1. What is your race? (select one or more):


American Indian

Alaska Native

Native Hawaiian

Other Pacific Islander

Asian

White

Black or African American

Other (please specify) _______________

21. What is the highest degree you have received (select one)?


Some high school, but no diploma or equivalent

High school diploma or equivalent

Some college but no degree

Associate's degree

Bachelor's degree

Master's degree

Doctoral degree or equivalent

Other (please specify): _________________





Please Continue to Next Page

22. What is your primary profession (select one)?


Counselor

Addictions professional

Social worker

Recovery specialist

Mental health professional

Criminal justice/law enforcement professional

Disease intervention specialist/investigator

Community health worker

Health educator

Educator (post-secondary or continuing)

Public or Business Administrator

Researcher

Physician

Physician assistant

Registered nurse

Licensed practical nurse

Advanced practice nurse

Pharmacist

Dentist

Other dental professional

Other (please specify)_____________


23. If you are a student, what is your primary field of study (select one)?


Not a student

Counseling

Psychology

Social Work

Medicine

Nursing

Pharmacology

Dentistry

Basic, translational or applied science

Criminal justice/law enforcement

Addiction

Education

Public health

Public or business administration

Other (please specify)



24. In which discipline(s) are you currently licensed or certified (select one or more)?


Not licensed or certified

Addictions prevention, treatment or recovery

Counseling

Psychology

Social Work

Medicine

Nursing

Pharmacology

Dentistry

Other (please specify)________________


25. Which best describes your role at your current workplace (select one)?


Clinician / care provider/direct service provider

Clinical Supervisor

Recovery Specialist

Manager / coordinator/administrator

Client / patient educator

Case manager

Prevention case manager


Counselor

Mental health therapist

Parole/Probation/Re-Entry Support

Outreach staff

Disease intervention/investigation

Resident / fellow

Teacher / faculty

Trainer / TA Provider

Group Facilitator

Not currently employed

Other (please specify)_____________


Please Continue to Next Page

26. Which best describes your principal employment setting (select one)?


Community or Faith-based service organization (CBO/FBO)

Government (federal, state or municipal)

State/local health department

School/university (academic department)

Hospital/Hospital-affiliated clinic

HMO/managed care organization

Solo/group private practice

Addictions treatment program (inpatient)

Addictions treatment program (outpatient)

Addictions treatment program (residential)

Recovery support program


School/university-based health clinic

Correctional facility

Probation/parole office

Local law enforcement department

Military/VA

Tribal/Indian Health Service

Community health center

Not currently employed

Other: (please specify) _________________

27. What is the zipcode of your principal employment setting? 


28. What about the technical assistance was most useful in supporting your work responsibilities?






29. How can the ATTC Network improve its technical assistance?








Participants – Please Write Your Unique Personal Code Here as Follows:

First Letter of Mother’s First Name:


First Letter of Mother’s Maiden Name:


First Digit of Social Security Number:


Last Digit of Social Security Number:




Thank you for completing our survey.

Return your survey to the Survey Administrator for your Session.


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 0930-0216.  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, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20852.

File Typeapplication/msword
File TitleForm Approved
AuthorJennifer Ellingwood
Last Modified ByWindows User
File Modified2016-06-07
File Created2016-06-07

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