Attachment 3. Stakeholder Survey, Wave 1
OMB No. 0930-0320
Expiration Date x/x/x
Welcome to the
National Evaluation of SAMHSA’s CABHI Projects Stakeholder Survey – Wave 1
[WELCOME] Thank you for taking time to complete the National Evaluation of SAMHSA’s CABHI Projects Stakeholder Survey. The questions in this survey are about your knowledge of and experience with [NAME OF GRANTEE ORGANIZATION]’s grant [PROJECT NAME].
Please click the “Continue” button below to proceed. If you are not affiliated with [NAME OF GRANTEE ORGANIZATION]’s grant [PROJECT NAME], please click here. [PROGRAMMER NOTE: IF R CLICKS HERE SKIP TO TERMINATE.]
[PROGRAMMER NOTE: INSERT “Continue” BUTTON]
_______________________________________________________________________________________________________
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 0930-0320. Public reporting burden for this collection of information is estimated to average 25 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.
[PROGRAMMER NOTE: RESPONDENTS DO NOT SEE THE CONTENTS]
MODULE B: STAKEHOLDER’S PERSONAL INVOLVEMENT 3
MODULE C: STAKEHOLDER’S ORGANIZATION 5
MODULE I: BASELINE COLLABORATION WITH OTHER ORGANIZATIONS 10
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[INTINTRO] For questions about the SAMHSA CABHI project, please answer only about [NAME OF GRANTEE ORGANIZATION]’s grant [PROJECT NAME], referred to throughout this survey as “SAMHSA CABHI project”. Other questions are about your organization and are explicitly identified as such.
The survey is estimated to take 25 minutes of your time, including the time it took to review the consent form. If you start and are unable to complete the survey, you can return to complete it at a later date using the same link. The survey will continue where you left off.
All the information you provide is private and will not be shared with anyone at the SAMHSA CABHI project. You will never be identified in any report that uses information from this Evaluation. Thank you again for your support.
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[STAKEINTRO] We will start with questions about your personal involvement with the SAMHSA CABHI project.
[STAKE1]
Which of the following best describes your role(s) or position(s) in this SAMHSA CABHI project? (check all that apply)
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Government official
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[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[STAKETRANS1] Please indicate whether the following describes your involvement in this SAMHSA CABHI project.
[STAKE2]
I helped plan for or prepare the initial project grant application.
Yes [1]
No [2]
[STAKE3]
I have been involved since the project was originally funded.
Yes [1]
No [2]
[STAKE3B]
Approximately what month and year did you become involved?
_ _ / _ _ [NUMERIC ACCEPT 2 CHARACTERS FOR MONTH AND 2 CHARACTERS FOR YEAR]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[STAKE4]
I regularly attend project stakeholder or advisory/consortium meetings.
Yes [1]
No [2]
[STAKE5]
I am directly involved with the project.
Yes [1]
No [2]
MODULE C: STAKEHOLDER’S ORGANIZATION
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: Project Name: [INSERT PROJECT NAME]
[ORGINTRO] The following questions are to describe your organization and the core services it provides to clients in general, not limited to CABHI project clients.
[ORG1_1]
As part of its core services, does your organization provide behavioral healthcare?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_1=1, GET ORG1_1B; ELSE SKIP TO ORG1_2]
[ORG1_1B]
Which behavioral service(s) does your organization provide? (Check all that apply)
Substance abuse treatment
Mental health treatment
Integrated substance abuse and mental health treatment
HIV/AIDS prevention or treatment
[ORG1_2]
As part of its core services, does your organization provide primary healthcare?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_2=1, GET ORG1_2B; ELSE SKIP TO ORG1_3]
[ORG1_2B]
In which setting(s) does your organization provide primary healthcare? (Check all that apply)
Hospital
Outpatient clinic
Other, please specify: ______________________________________
[ORG1_3]
As part of its core services, does your organization provide HIV/AIDS prevention or treatment?
Yes [1]
No [2]
[ORG1_4]
As part of its core services, does your organization provide housing services and supports, including identifying and securing housing?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_4=1, GET ORG1_4B; ELSE SKIP TO ORG1_5]
[ORG1_4B]
What type(s) of housing services and supports does your organization provide? (Check all that apply)
Coordinated entry (including through the HUD Continuum of Care)
Management or administration of housing vouchers
Other, for example help with applications or interviews or help maintaining housing
[ORG1_5]
As part of its core services, does your organization provide or manage housing?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_5=1, GET ORG1_5B; ELSE SKIP TO ORG1_6]
[ORG1_5B]
What type(s) of housing does your organization provide? (Check all that apply)
Permanent public housing
Permanent, privately owned housing
Transitional housing
Emergency shelter
Other, please specify: ______________________________________
[ORG1_6]
As part of its core services, does your organization provide social services (other than any addressed in preceding questions)?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_6=1, GET ORG1_6B; ELSE SKIP TO ORG1_7]
[ORG1_6B]
What type(s) of social services does your organization provide? (Check all that apply)
Case management
Drop-in center
Soup kitchen or other meals
Food pantry
Other, please specify: ______________________________________
[ORG1_7]
As part of its core services, does your organization provide educational services (other than any addressed in preceding questions)?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_7=1, GET ORG1_7B; ELSE SKIP TO ORG1_8]
[ORG1_7B]
What type(s) of educational services does your organization provide? (Check all that apply)
K – 12 (other than GED)
GED
Post-secondary
Other, please specify: ______________________________________
[ORG1_8]
As part of its core services, does your organization provide employment services (other than any addressed in preceding questions)?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_8=1, GET ORG1_8B; ELSE SKIP TO ORG1_9]
[ORG1_8B]
What type(s) of employment services does your organization provide? (Check all that apply)
Job training/vocational rehab
Job placement
Other employment support services (e.g. help with resume, interviewing skills, presentation)
[ORG1_9]
As part of its core services, does your organization focus on any particular groups (i.e. target groups or specific populations)?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_9=1, GET ORG1_9B; ELSE SKIP TO ORG1_10]
[ORG1_9B]
What type(s) of employment services does your organization provide? (Check all that apply)
Families
Unaccompanied youth, including runaway youth
Women
LGBTQ individuals
Veterans
Individuals with HIV/AIDS
Other, please specify: ______________________________________
[ORG1_10]
As part of its core services, does your organization provide peer support services?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_10=1, GET ORG1_10B; ELSE SKIP TO ORG1_11]
[ORG1_10B]
Is your organization peer-led or peer-run?
Yes [1]
No [2]
[ORG1_11]
Is your organization a government agency, authority or other entity?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_11=1, GET ORG1_11B; ELSE SKIP TO ORG1_12]
[ORG1_11B]
What type(s) of government entity is your organization? (Check all that apply)
Substance abuse agency/authority
Mental health agency/authority
Housing agency/authority
Medical/health agency
Social services agency
Veterans administration
Benefits, other than VA (for example, Social Security, Medicaid)
Employment services agency/authority
Criminal justice agency
Other, please specify: ______________________________________
[ORG1_11C]
What level of government is your organization? (Check all that apply)
Local, for example city or county
State or territory
Federal
[ORG1_12]
[PROGRAMMER NOTE: IF ORG1_1=2 AND ORG1_2=2 AND ORG1_3=2 AND ORG4_1=2 AND ORG1_5=2 AND ORG1_6=2 AND ORG1_7=2 AND ORG1_8=2 AND ORG1_9=2 AND ORG1_10=2, GET ORG1_12; ELSE SKIP TO ORG_INTRO2]
[ORG1_12]
It appears that your organization is not any of the organization types address above. Please indicate what type of organization it is: [SPECIFY] ________________________________
[ORG1_13]
Does your organization serve as the lead agency for Coordinated Entry?
Yes [1]
No [2]
The next questions ask about your organization’s involvement in the SAMHSA CABHI project.
[ORG2]
Has your organization received funding from this SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[ORG3]
Does your organization provide substance abuse or mental health treatment or case management to SAMHSA CABHI project clients?
Yes [1]
No [2]
Don’t know [8]
[ORG4]
Does your organization provide primary healthcare or HIV/AIDS services to SAMHSA CABHI project clients?
Yes [1]
No [2]
Don’t know [8]
[ORG5]
Does your organization provide wraparound or support services (e.g., support securing or maintaining housing, daily living skills, vocational or education services, or family services) to SAMHSA CABHI project clients?
Yes [1]
No [2]
Don’t know [8]
[ORG6]
Does your organization provide permanent housing to SAMHSA CABHI project clients?
Yes [1]
No [2]
Don’t know [8]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF ORG3=1, OR ORG4=1, OR ORG5=1, OR ORG6=1, GET ORG7; ELSE SKIP TO COLLABINTRO]
[ORG7]
How many SAMHSA Homeless project clients has your organization served to date? Please count a single client only once. If you are not certain of the exact amount, please provide your best estimate.
______________ [ALLOW 4; NUMERIC ONLY]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[COLLABINTRO]
The next questions refer to your organization’s collaboration with other organizations that are currently involved with the SAMHSA CABHI project.
[COLLAB1]
Prior to the SAMHSA CABHI project (or working on the grant application), how often did your organization collaborate with other organizations in each of the following areas?
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Never [1] |
Rarely [2] |
Sometimes [3] |
Often [4] |
Don’t know [8] |
Social services providers [COLLAB1_1] |
○ |
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Drop-in centers [COLLAB1_2] |
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Medical (primary/specialized) care providers [COLLAB1_3] |
○ |
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Peers/consumers [COLLAB1_4] |
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[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[COLLAB2]
Prior to the SAMHSA CABHI project (or working on the grant application), how often did your organization collaborate with other organizations in each of the following areas?
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Never [1] |
Rarely [2] |
Sometimes [3] |
Often [4] |
Don’t know [8] |
Substance abuse treatment providers [COLLAB2_1] |
○ |
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State substance abuse authority [COLLAB2_2] |
○ |
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Mental health treatment providers [COLLAB2_3] |
○ |
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State mental health authority [COLLAB2_4] |
○ |
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Housing providers [COLLAB3_1] |
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State or local housing authority [COLLAB3_2] |
○ |
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Local continuum of care [COLLAB3_3] |
○ |
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Shelters [COLLAB3_4] |
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[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[COLLAB4]
Prior to the SAMHSA CABHI project (or working on the grant application), how often did your organization collaborate with other organizations in each of the following areas?
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Never [1] |
Rarely [2] |
Sometimes [3] |
Often [4] |
Don’t know [8] |
Education providers [COLLAB4_1] |
○ |
○ |
○ |
○ |
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Employment or job training providers [COLLAB4_2] |
○ |
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Veterans agencies [COLLAB4_3] |
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Criminal justice agencies [COLLAB4_4] |
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State Medicaid office [COLLAB5_1] |
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Family advocacy groups [COLLAB5_2] |
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Policy-makers/legislators [COLLAB5_3] |
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Research/evaluation [COLLAB5_4] |
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[COLLAB5
Since the start of the SAMHSA CABHI project, how often has your organization collaborated with other local organizations in each of the following areas?
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Never [1] |
Rarely [2] |
Sometimes [3] |
Often [4] |
Don’t know [8] |
Social services providers [COLLAB5_1] |
○ |
○ |
○ |
○ |
○ |
Drop-in centers [COLLAB5_2] |
○ |
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Medical (primary/specialized) care providers [COLLAB5_3] |
○ |
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○ |
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Peers/consumers [COLLAB5_4] |
○ |
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[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[COLLAB6]
Since the start of the SAMHSA CABHI project, how often has your organization collaborated with other local organizations in each of the following areas?
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Never [1] |
Rarely [2] |
Sometimes [3] |
Often [4] |
Don’t know [8] |
Substance abuse treatment providers [COLLAB6_1] |
○ |
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State substance abuse authority [COLLAB6_2] |
○ |
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Mental health treatment providers [COLLAB6_3] |
○ |
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State mental health authority [COLLAB6_4] |
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[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[COLLAB7]
Since the start of the SAMHSA CABHI project, how often has your organization collaborated with other local organizations in each of the following areas?
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Never [1] |
Rarely [2] |
Sometimes [3] |
Often [4] |
Don’t know [8] |
Housing providers [COLLAB7_1] |
○ |
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State or local housing authority [COLLAB7_2] |
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Local continuum of care [COLLAB7_3] |
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Shelters [COLLAB7_4] |
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[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[COLLAB8]
Since the start of the SAMHSA CABHI project, how often has your organization collaborated with other local organizations in each of the following areas?
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Never [1] |
Rarely [2] |
Sometimes [3] |
Often [4] |
Don’t know [8] |
Education providers [COLLAB8_1] |
○ |
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○ |
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Employment or job training providers [COLLAB8_2] |
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Veterans agencies [COLLAB8_3] |
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Criminal justice agencies [COLLAB8_4] |
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State Medicaid office [COLLAB8_5] |
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Family advocacy groups [COLLAB8_6] |
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Policy-makers/legislators [COLLAB8_7] |
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Research/evaluation [COLLAB8_8] |
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[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
The next set of questions asks about different types of collaboration with SAMHSA grant partners in 4 categories: (1) substance abuse or mental health treatment providers, (2) healthcare providers or agencies, (3) public housing authorities and/or housing providers, and (4) other types of organizations, for example criminal justice agencies, veterans affairs, or the local HUD Continuum of Care.
Please include collaboration with partners in your organization ONLY IF the partner works in a category different from your own; do not include collaboration with partners in your organization who work in your category. Include collaboration with partners from other organizations whether they work in your category or a different category.
[COLLAB9]
How often do you collaborate with one or more local substance abuse or mental health treatment provider partners to:
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Never [1] |
Rarely [2] |
Sometimes [3] |
Often [4] |
Don’t know [8] |
Work with the partner to identify, recruit, and/or screen clients [COLLAB9_1] |
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Make referrals to the partner [COLLAB9_2] |
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Receive referrals from the partner [COLLAB9_3] |
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Exchange information on specific clients [COLLAB9_4] |
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Work together to implement HIT solutions to support effective coordination of care for the population(s) of focus [COLLAB9_5] |
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Collaborate on services for one or more individual clients [COLLAB9_6] |
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Plan coordinated approaches to serving the population(s) of focus [COLLAB9_7] |
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Plan coordinated approaches to funding current services for client [COLLAB9_8] |
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Plan coordinated approaches to sustaining services for the population(s) of focus [COLLAB9_9] |
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[COLLAB10]
How often do you collaborate with one or more local healthcare provider partners to:
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Never [1] |
Rarely [2] |
Sometimes [3] |
Often [4] |
Don’t know [8] |
Work with the partner to identify, recruit, and/or screen clients [COLLAB10_1] |
○ |
○ |
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○ |
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Make referrals to the partner [COLLAB10_2] |
○ |
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Receive referrals from the partner [COLLAB10_3] |
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Exchange information on specific clients [COLLAB10_4] |
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Work together to implement HIT solutions to support effective coordination of care for the population(s) of focus [COLLAB10_5] |
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Collaborate on services for one or more individual clients [COLLAB10_6] |
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Plan coordinated approaches to serving the population(s) of focus [COLLAB10_7] |
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Plan coordinated approaches to funding current services for client [COLLAB10_8] |
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Plan coordinated approaches to sustaining services for the population(s) of focus [COLLAB10_9] |
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[COLLAB11]
How often do you collaborate with one or more local public housing authority and/or housing provider partners to:
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Never [1] |
Rarely [2] |
Sometimes [3] |
Often [4] |
Don’t know [8] |
Work with the partner to identify, recruit, and/or screen clients [COLLAB11_1] |
○ |
○ |
○ |
○ |
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Make referrals to the partner[COLLAB11_2] |
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Receive referrals from the partner [COLLAB11_3] |
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Exchange information on specific clients [COLLAB11_4] |
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Work together to implement HIT solutions to support effective coordination of care for the population(s) of focus [COLLAB11_5] |
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Collaborate on services for one or more individual clients [COLLAB11_6] |
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Plan coordinated approaches to serving the population(s) of focus [COLLAB11_7] |
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Plan coordinated approaches to funding current services for client [COLLAB11_8] |
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Plan coordinated approaches to sustaining services for the population(s) of focus [COLLAB11_9] |
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[COLLAB12]
How often do you collaborate with one or more local [SELECTED OTHER] agencies or organizations partners to:
[PROGRAMMING NOTE: SELECT THE HIGHEST RATING AMONG COLLAB1_1, COLLAB1_2, COLLAB1_4, COLLAB4_1, COLLAB4_2, COLLAB4_3, COLLAB4_4, COLLAB4_5, COLLAB4_6, COLLAB4_7, AND COLLAB4_8; USE THAT LABEL IN “SELECTED OTHER” IMMEDIATELY ABOVE. IF TWO OR MORE RATINGS ARE TIED, RANDOMLY SAMPLE ONE OF THOSE WITH THE HIGHEST RATINGS.]
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Never [1] |
Rarely [2] |
Sometimes [3] |
Often [4] |
Don’t know [8] |
Work with the partner to identify, recruit, and/or screen clients [COLLAB12_1] |
○ |
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Make referrals to the partner [COLLAB12_2] |
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Receive referrals from the partner [COLLAB12_3] |
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Exchange information on specific clients [COLLAB12_4] |
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Work together to implement HIT solutions to support effective coordination of care for the population(s) of focus [COLLAB12_5] |
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Collaborate on services for one or more individual clients [COLLAB12_6] |
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Plan coordinated approaches to serving the population(s) of focus [COLLAB12_7] |
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Plan coordinated approaches to funding current services for client [COLLAB12_8] |
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Plan coordinated approaches to sustaining services for the population(s) of focus [COLLAB12_9] |
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[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[CLOSE1]
Finally, please provide any additional information about the SAMHSA CABHI project that you think is important and would like to share. We are especially interested in “lessons learned” – things that went well, or not so well, from the grant start-up that you would like to share (anonymously) with SAMHSA and future grantees.
[ALLOW 1000]
THANK YOU VERY MUCH for participating!
Information from key stakeholders like you will help practitioners, policy makers, researchers and funders better understand the efforts of SAMHSA CABHI projects, including factors contributing to success, which we hope will improve future efforts to reduce homelessness and provide clients and consumers the services they need.
[NEW SCREEN]
[IF STAKEHOLDER, GRANT ORGANIZATION OR PROJECT NAME NOT ACCURATE]
[TERMINATE]
We are sorry for the confusion. A team member from the National Evaluation of SAMHSA’s Homeless Programs will look into the problem and get back to you.
If you have any questions or need to speak with someone about this National Evaluation of SAMHSA’s Homeless Programs or the Stakeholder survey, please contact Jim Trudeau, RTI International Project Director, via email [email protected], or phone, toll-free 1-877-653-1240.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Ariana Napier |
File Modified | 0000-00-00 |
File Created | 2021-01-22 |