Form All IC Forms All IC Forms All IC Forms

Center for Mental Health Services
Session Reporting Form
Instructions
Instructions to Agency Staff/Trainers

The Center for Mental Health Services (CMHS) is committed to improving the
mental health services delivered to HIV/AIDS affected populations and requests
that you complete the attached Session Reporting Form. This form requests
descriptive information on the education/training session and must be completed
by agency staff or trainers at the end of each training session. The information
collected will enable CMHS to evaluate the effectiveness of the effort in meeting
its objectives to provide state-of-the-art information to a diverse mixture of
training participants. CMHS and the sponsoring agency intend to use the
information gathered from the evaluation to improve the quality of training and
to ensure continued funding for HIV/AIDS provider education programs.
Public reporting burden for this collection of information is estimated to
average 10 minutes per response, including time for reviewing instructions and
completing the survey form. 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. 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 0930-0195.

Thank you, your help is appreciated.

Substance Abuse and Mental Health Services Administration

MHCPE
Mental Health Care Provider
Education in HIV/AIDS
Program

Mental Health Care Provider
Education in HIV/AIDS
Programs

Session Reporting Form (SRF)
Note: This is to be completed by a project administrator.

Date:
month

day

Instructions: Please respond to the
items by filling in the appropriate oval
using a No. 2 pencil or dark blue or
black pen.

year

CMHS Site ID #

Form Approved
OMB. No. 0930-0195
Exp. Date XX/XX/XXXX

Session Number

Trainer ID#

Correct

Incorrect

Title of Training or Conference

1. Language Spoken During Session (Please choose only ONE)
English

Spanish

Both

2. Total Number of Participants in Session:
3. Type of Curriculum Used (Mark the single best answer)
General curriculum
CMHS Ethics curriculum
Adherence curriculum
CMHS “The Brain and Behavior” curriculum
Other Specialized curriculum
4. Workshop Length (actual hours of training): hours

Substance Use and HIV
Neuropsychiatric curriculum

minutes

5. Language of Evaluation Forms (Please choose only ONE)
English
Spanish
Both
6. Co-sponsoring Organizations (Mark all that apply)
None
College or University
AIDS Education and Training Centers
Community Health Center
Area Health Education Center
State/Local Health Department
State/Local Office of Mental Health
Chemical Dependency Program
Health Professions School
Other_______________________

State/Local Drug/Alcohol Department
Hospital/Hospital-Based Clinic
CBO providing AIDS services
Professional Association

7. Please indicate the primary and secondary topics to be covered during training (Circle “1” for primary, “2” for secondary).
1 - - 2 Mental health aspects of HIV
1 - - 2 Legal and ethical issues
1 - - 2 Children and HIV
1 - - 2 Treatments for HIV disease
1 - - 2 HIV counseling and testing
1 - - 2 Taking a substance use history
1 - - 2 Adherence to treatment issues
issues
1 - - 2 Severe mental illness
1 - - 2 Neuropsychiatric aspects of HIV
1 - - 2 Women and HIV
1 - - 2 Taking a sexual history
1 - - 2 Culturally competent practices
1 - - 2 Prevention of HIV infection
1 - - 2 Other sexually transmitted diseases
1 - - 2 Substance abuse issues
1 - - 2 Working with affected
1 - - 2 Perinatal HIV transmission
1 - - 2 Epidemiology of HIV/AIDS
family/significant others
1 - - 2 Older adults and HIV
1 - - 2 HIV disease progression
1 - - 2 Adolescents and HIV
1 - - 2 Other (specify, e.g., spirituality, rural
1 - - 2 Pharmacological issues
1 - - 2 Sexual orientation/sensitivity
populations)

For neuropsychiatric curricula only:
1 - - 2 Central nervous system complications of HIV
1 - - 2 Cognitive and other mental disorders associated with HIV
1 - - 2 Other______________________________

1 - - 2 Psychological factors affecting HIV medical status
1 - - 2 Psychopharmacology and drug-drug interactions
1 - - 2 Assessment/diagnosis of neuropsychiatric complications

For site use only:

PLEASE TURN OVER

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

8. Instruments administered (Mark all that apply)
Participant Feedback Form
Site-specific forms: if yes, number of different forms. ______________
9. Involvement of Disclosed HIV-positive Individuals in Training (Enter numbers for each)
Trainer (s) ____________ Guest Speaker( s)____________ Panelist (s)__________

Video (s)__________

Other _______________________

10. Face-to-Face Education Strategies/Methods employed. If this is distance learning, skip to Question 12.
(Please indicate approximate time spent in hours and minutes on each period. The total time should equal length listed
in questions 4.)

.
Grand Rounds
______.______
Lecture
______.______
Question and Answer ______.______
Case Studies

______ ______

.
_______.______
_______.______
_______.______
_______.______

.
______._____
______._____

Panel Discussion _______ ______

Small Group “Breakouts”______ _____

Role Play

Interactive Exercises

Self-Instruction
Videos

Other ____________________________________________

Structured Discussions

11. Educational Materials Distributed to Trainees during Face-to-Face Sessions (Mark all that apply)
Pamphlets
Copies of overheads/slides
Articles
Resource lists/directories
Chart notes
Books
Video tapes
Worksheets
Prevention resources
Other_________________________

Case studies
Curriculum materials

12. Distance Learning Modality/Method (Mark the single best answer)
Telephone conference - interactive
Telephone conference - Non-interactive
Video conference - interactive
Video conference - Non-interactive
Web-based training, excluding materials downloaded from web sites
Other, please specify ___________________________________________
13. Participants were asked to complete the following knowledge gain sections (Mark all that apply)
Entire form
Questions 1 to 20
Special Populations and Issues
HIV-Related Conditions and Treatment Aspects
Transmission and Prevention

THANK YOU FOR PARTICIPATING
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 0930-0195. 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.

Center for Mental Health Services
Participant Feedback Form
Instructions
The training you are attending is funded by The Center for Mental Health
Services (CMHS), a Federal agency with a mission to improve mental health
services delivered to HIV/AIDS affected populations. CMHS requests that you
complete the attached form in order to assist in assessing the effectiveness of
the effort in meeting its objectives to provide state-of-the-art information to a
diverse mixture of training participants. CMHS and the sponsoring agency
intend to use the information gathered from this feedback to improve the quality
of training and to ensure continued funding for HIV/AIDS provider education
programs.
Public reporting burden for this collection of information is estimated to average
10 minutes per response, including time for reviewing instructions and
completing the feedback form. 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. 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 0930-0195.
Completion of the feedback form is voluntary. All information gathered from
the form is anonymous. It is important that you fill in the Anonymous
Unique Identifier at the top of the form. This identifier will be used to
match your responses from this form with responses from other forms that
you may complete as part of this training. Please use a pen or pencil to darken
each circle completely. Return the completed form to the place designated by the
training staff.

Thank you, your help is appreciated.

Substance Abuse and Mental Health Services Administration

MHCPE
Mental Health Care Provider
Education in HIV/AIDS
Programs

Mental Health Care Provider Education in HIV/
AIDS Programs; Substance Abuse and Mental
Health Services Administration (SAMHSA)/Center
for Mental Health Services (CMHS)

Adherence Participant Feedback Form
This survey will help us evaluate and improve the training program.
Completion of the feedback form is voluntary.

Form Approved
OMB No. 0930-0195
Exp. 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 0930-0195. 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.

Instructions: Please respond to the items by filling in the appropriate oval
using a No. 2 pencil, dark blue or black pen.
1. Anonymous Unique Identifier: This permits training
sites to determine if you have attended multiple trainings.
Last 4 digits of social
security number

month

day
Date of Birth

2. Reasons for attending training (Mark the SINGLE BEST
answer):
CMEs/CEUs
Knowledge/skill development
Friend/family with HIV
Other: ____________
Job requirement
3. Gender:

Male

Female

4a. Are you of Hispanic or Latino descent or origin?
Yes
No
4b. Race: (Select one or more)
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
5. How much formal schooling have you received?
(Please choose only ONE)
Less than high school
M.D.
High school/GED
Doctoral Degree (non-M.D.)
Associate Degree
M.D. & Doctoral Degree
Bachelor’s Degree
Other Professional Degree
Master’s Degree
Other: _________
6. What facility BEST describes the primary setting where
you work? (Please choose only ONE)
Academic Institution
Long-term Care Facility
Community Based
Non-hospital Mental
Organization
Health Clinic/Agency
Correctional Facility
Private Practice
Home Health/Visiting
Public Health Agency/Clinic
Hospice
Religious Organization
Hospital Mental Health
Substance Abuse Treatment
Clinic/Unit
Not working
Other Hospital
Other: _________________
Clinic/Unit

Correct

Incorrect

8. Which of the following describe your work at the
facility identified in Item 6 above? (Mark all that apply)
Administrator/Supervisor
Case Manager
Clergy/Pastoral Worker
Counselor
Faculty/Teacher
Health Educator
Nurse (LPN, RN, APN)
Outreach Worker

Physician (not a Psychiatrist)
Psychiatrist
Psychologist
Social Worker (BSW,MSW)
Student
Volunteer/Buddy
Other: ___________

9. Do you provide services directly to HIV-positive individual(s)?
Yes

No

A. If YES, in what capacity? (Mark the SINGLE BEST answer)
Case Manager
Clergy/Pastoral Worker
Counselor
Educator
Nurse (LPN, RN, APN)
Outreach Worker
Psychiatrist

Physician
(not a Psychiatrist)
Psychologist
Social Worker (BSW,MSW)
Student (specify)_______
Volunteer/Buddy
Other: ___________

B. If NO, what is your main job/capacity? (Mark the
SINGLE BEST answer)
Administrator/Supervisor
Clergy/Pastoral worker
Faculty/Teacher
Health Educator

Researcher
Student
Volunteer
Other: ________

10. Do you provide direct services to family members/significant
others of HIV-positive individual(s)?
Yes

No
10 years or more
Between 5-10 years
2-5 years
Less than 2 years
None

11. Please indicate the number of years
that you have provided service in the
following areas:

Direct HIV-related clinical mental
health services (e.g., therapy)………………...
7. Which geographical description BEST describes where this
Other direct services to HIV-positive
facility is located?
individuals (e.g., primary health care).……….
Any other HIV-related assistance to
Urban
Suburban
HIV-positive individuals (e.g., driving
Rural
Not Applicable
PLEASE TURN OVER someone to an appointment)…..……………..

Strongly Agree

For the following questions, select a rating that reflects
your degree of agreement with the statement presented.

Agree
Neutral
Disagree
Strongly Disagree

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
12. This training session was well organized..…...
13. The information/skills training was useful.……
14. I was satisfied with this training…..……….......
15. I would recommend this training to others..….
16. The HIV-positive guest speaker/panel was
important to my training experience
(skip if not applicable to session)……………...

Already willing/capable/comfortable
17. As a result of this training, I am more
comfortable treating and/or caring
for HIV-positive and HIV-affected
individuals…………………………..…….
18. As a result of this training, I am more
willing to treat and/or care for HIVpositive and HIV-affected individuals…..
19. As a result of this training, I am more
capable of treating and/or caring for
HIV-positive and HIV-affected
individuals………………………….……...

20. My level of prior knowledge of the information/skills presented at this training was…
Low
Moderate
High

To what extent has this training increased your HIV/AIDS knowledge/skills
in the following areas: (Indicate if topic was not covered in training.)

To a very great extent
To a great extent
To some extent
To a little extent
Not at all

Topic not covered
Module I: Historical Perspective
21. Awareness of my own attitudes regarding HIV and its treatment…..……………………………………
22. A historical perspective on HIV treatment………………………...…..……………………………………
23. Challenges clients face when deciding about complex treatment options for HIV……….……………
24. The role of mental health care providers in helping clients cope with living with HIV……………..…..
Module II: General Medical Update
25. The benefits and limitations of current treatments for HIV…………….………………………………...
26. My ability to respond to client concerns about new HIV treatments…..………………………………..
27. The uses of HIV viral load measurement………………………………………………………………….
28. The role of medical care providers in helping clients to make informed treatment decisions..……...
Module III: HIV Medication Adherence and the Mental Health Care Provider
29. The implications of less than full medication adherence in HIV treatment………………….………....
30. The unique role of mental health care providers in assisting clients’ treatment decision-making.…..
31. Difficulties clients encounter in adhering to HIV medications...…………………………………….……
32. The unique role of mental health care providers in helping clients adhere to HIV treatment...……...
33. New challenges for clients responding positively to HIV treatment...….……………………………….
34. Cues, reminders and tools clients can use to increase adherence…….……………………………….
35. The particular challenges women encounter in adhering to HIV medications….……………………...
36. Offering nonjudgmental support to non-adherent clients…………………….…………………………..
37. The five components of the IDEAS model…………..……………………………………………………..
Module IV: Drug Interactions Between Psychotropic Medications and Treatments for HIV
38. The most commonly used drugs for the treatment of HIV…………………...…………………………..
39. Potential drug interactions between HIV medications and psychotropic drugs….…………………….

40. How will you use what you have learned in this training in your HIV/AIDS work?

41. How could this training be improved?

THANK YOU FOR PARTICIPATING!
To be filled out by education site staff:____ ______ ______ ______ / ______ _____ ___
MHS Site ID#

Session Number

Date_____/____/_______
month

day

year

Ethics Participant Feedback Form

Mental Health Care Provider Education in HIV/
AIDS Programs; Substance Abuse and Mental
Health Services Administration (SAMHSA)/Center
for Mental Health Services (CMHS)

This survey will help us evaluate and improve the training program.
Completion of the feedback form is voluntary.

Form Approved
OMB No. 0930-0195
Exp. 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 0930-0195. 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.

Instructions: Please respond to the items by filling in the appropriate oval
using a No. 2 pencil, dark blue or black pen.
1. Anonymous Unique Identifier: This permits training
sites to determine if you have attended multiple trainings.
Last 4 digits of social

month

day
Date of Birth

2. Reasons for attending training (Mark the SINGLE BEST
answer):
CMEs/CEUs
Knowledge/skill development
Friend/family with HIV
Other: ____________
Job requirement
3. Gender:

Male

Female

4a. Are you of Hispanic or Latino descent or origin?
Yes
No
4b. Race: (Select one or more)
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
5. How much formal schooling have you received?
(Please choose only ONE)
Less than high school
M.D.
High school/GED
Doctoral Degree (non-M.D.)
Associate Degree
M.D. & Doctoral Degree
Bachelor’s Degree
Other Professional Degree
Master’s Degree
Other: _________
6. What facility BEST describes the primary setting where
you work? (Please choose only ONE)
Academic Institution
Long-term Care Facility
Community Based
Non-hospital Mental
Organization
Health Clinic/Agency
Correctional Facility
Private Practice
Home Health/Visiting
Public Health Agency/Clinic
Hospice
Religious Organization
Hospital Mental Health
Substance Abuse Treatment
Clinic/Unit
Not working
Other Hospital
Other: _________________
Clinic/Unit

Correct

Incorrect

8. Which of the following describe your work at the
facility identified in Item 6 above? (Mark all that apply)
Administrator/Supervisor
Case Manager
Clergy/Pastoral Worker
Counselor
Faculty/Teacher
Health Educator
Nurse (LPN, RN, APN)
Outreach Worker

Physician (not a Psychiatrist)
Psychiatrist
Psychologist
Social Worker (BSW,MSW)
Student
Volunteer/Buddy
Other: ___________

9. Do you provide services directly to HIV-positive individual(s)?
Yes

No

A. If YES, in what capacity? (Mark the SINGLE BEST answer)
Case Manager
Clergy/Pastoral Worker
Counselor
Educator
Nurse (LPN, RN, APN)
Outreach Worker
Psychiatrist

Physician
(not a Psychiatrist)
Psychologist
Social Worker (BSW,MSW)
Student (specify)_______
Volunteer/Buddy
Other: ___________

B. If NO, what is your main job/capacity? (Mark the
SINGLE BEST answer)
Administrator/Supervisor
Clergy/Pastoral worker
Faculty/Teacher
Health Educator

Researcher
Student
Volunteer
Other: ________

10. Do you provide direct services to family members/significant
others of HIV-positive individual(s)?
Yes

No
10 years or more
Between 5-10 years
2-5 years
Less than 2 years
None

11. Please indicate the number of years
that you have provided service in the
following areas:

Direct HIV-related clinical mental
health services (e.g., therapy)………………...
7. Which geographical description BEST describes where this
Other direct services to HIV-positive
facility is located?
individuals (e.g., primary health care).……….
Any other HIV-related assistance to
Urban
Suburban
HIV-positive individuals (e.g., driving
Rural
Not Applicable
PLEASE TURN OVER someone to an appointment)…..……………..

Strongly Agree

For the following questions, select a rating
that reflects your degree of agreement with
the statement presented.

Agree
Neutral
Disagree
Strongly Disagree

12. This training session was well organized……………………………………………………………..…..………...
13. The information/skills training was useful……………………………………………………………….……..…..
14. I would recommend this training to others………………………………………………………………..….…….
15. I was satisfied with this training……………………………………………………………………………..……....
16. The case studies were helpful/useful (skip if not applicable to session)……………………………………....

Strongly Agree

The following ethical issues are common to the treatment of
persons with HIV/AIDS. Select a rating that reflects your degree
of agreement with the statement presented.

Agree
Neutral
Disagree
Strongly Disagree

THIS WORKSHOP HELPED ME:
17. Develop an awareness of the ethical issues involved in providing mental health services to
people living with HIV/AIDS…………………………………………………………………………………………..
18. Develop an awareness of the legal issues involved in providing mental health services to people
living with HIV/AIDS…………………………………………………………………………………………………....
19. Learn a systematic decision-making process that can be used to address legal/ethical issues in
cases involving HIV/AIDS……………………………………………………………………………………………..
20. Understand how personal reactions of mental health providers can affect judgments in HIV/AIDS
cases that pose ethical and/or legal concerns……………………………………………………………………...
21. Learn the skills to apply a systematic decision-making process in cases involving HIV/AIDS………………..
22. Describe five fundamental ethical principles that can be used to systematically analyze complex
legal/ethical issues involving HIV/AIDS……………………………………………………………………………...
23. Learn to distinguish between the facts of a case and its assumptions or interpretations……………………...
24. Develop a better understanding of what to expect from a legal consultation associated with cases
involving HIV/AIDS…………………………………………………………………………………………………….
25. Learn to develop an initial plan to address an ethical question based on the clinical issues
of the case……………………………………………………………………………………………………………..
26. How will you use what you have learned in this training in your HIV/AIDS work?

27. How could this training be improved?
THANK YOU FOR PARTICIPATING!

To be filled out by education site staff:______ ______ ______ ______ / ______ _____ ______
CMHS Site ID#

Session Number

Date_____/_____/______
month

day

year

Neuropsychiatric Participant Feedback Form
Mental Health Care Provider Education in HIV/
AIDS Programs; Substance Abuse and Mental
Health Services Administration (SAMHSA)/Center
for Mental Health Services (CMHS)

This survey will help us evaluate and improve the training program.
Completion of the feedback form is voluntary.

Form Approved
OMB No. 0930-0195
Exp. 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 0930-0195. 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.

Instructions: Please respond to the items by filling in the appropriate oval
using a No. 2 pencil, dark blue or black pen.
1. Anonymous Unique Identifier: This permits training
sites to determine if you have attended multiple trainings.
Last 4 digits of social

month

day
Date of Birth

2. Reasons for attending training (Mark the SINGLE BEST
answer):
CMEs/CEUs
Knowledge/skill development
Friend/family with HIV
Other: ____________
Job requirement
3. Gender:

Male

Female

4a. Are you of Hispanic or Latino descent or origin?
Yes
No
4b. Race: (Select one or more)
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
5. How much formal schooling have you received?
(Please choose only ONE)
Less than high school
M.D.
High school/GED
Doctoral Degree (non-M.D.)
Associate Degree
M.D. & Doctoral Degree
Bachelor’s Degree
Other Professional Degree
Master’s Degree
Other: _________
6. What facility BEST describes the primary setting where
you work? (Please choose only ONE)
Academic Institution
Long-term Care Facility
Community Based
Non-hospital Mental
Organization
Health Clinic/Agency
Correctional Facility
Private Practice
Home Health/Visiting
Public Health Agency/Clinic
Hospice
Religious Organization
Hospital Mental Health
Substance Abuse Treatment
Clinic/Unit
Not working
Other Hospital
Other: _________________
Clinic/Unit

Correct

Incorrect

8. Which of the following describe your work at the
facility identified in Item 6 above? (Mark all that apply)
Administrator/Supervisor
Case Manager
Clergy/Pastoral Worker
Counselor
Faculty/Teacher
Health Educator
Nurse (LPN, RN, APN)
Outreach Worker

Physician (not a Psychiatrist)
Psychiatrist
Psychologist
Social Worker (BSW,MSW)
Student
Volunteer/Buddy
Other: ___________

9. Do you provide services directly to HIV-positive individual(s)?
Yes

No

A. If YES, in what capacity? (Mark the SINGLE BEST answer)
Case Manager
Clergy/Pastoral Worker
Counselor
Educator
Nurse (LPN, RN, APN)
Outreach Worker
Psychiatrist

Physician
(not a Psychiatrist)
Psychologist
Social Worker (BSW,MSW)
Student (specify)_______
Volunteer/Buddy
Other: ___________

B. If NO, what is your main job/capacity? (Mark the
SINGLE BEST answer)
Administrator/Supervisor
Clergy/Pastoral worker
Faculty/Teacher
Health Educator

Researcher
Student
Volunteer
Other: ________

10. Do you provide direct services to family members/significant
others of HIV-positive individual(s)?
Yes

No
10 years or more
Between 5-10 years
2-5 years
Less than 2 years
None

11. Please indicate the number of years
that you have provided service in the
following areas:

Direct HIV-related clinical mental
health services (e.g., therapy)………………...
7. Which geographical description BEST describes where this
Other direct services to HIV-positive
facility is located?
individuals (e.g., primary health care).……….
Any other HIV-related assistance to
Urban
Suburban
HIV-positive individuals (e.g., driving
Rural
Not Applicable
PLEASE TURN OVER someone to an appointment)…..……………..

Strongly Agree

For the following questions, select a rating that reflects
your degree of agreement with the statement presented.

Agree
Neutral
Disagree
Strongly Disagree

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

Already willing/capable/comfortable
17. As a result of this training, I am more
comfortable treating and/or caring
for HIV-positive and HIV-affected
individuals…………………………..…….
18. As a result of this training, I am more
willing to treat and/or care for HIVpositive and HIV-affected individuals…..
19. As a result of this training, I am more
capable of treating and/or caring for
HIV-positive and HIV-affected
individuals………………………….…….

12. This training session was well organized..…..
13. The information/skills training was useful.…..
14. I was satisfied with this training…………….....
15. I would recommend this training to others..…
16. The HIV-positive guest speaker/panel was
important to my training experience
(skip if not applicable to session)…………….

20. My level of prior knowledge of the information/skills
presented at this training was…
Low
Moderate

High

To a very great extent
To a great extent

To what extent has this training increased your HIV/AIDS knowledge/skills
in the following areas: (Indicate if topic was not covered in training.)

To some extent
To a little extent
Not at all

Topic not covered
Module I: Historical Perspective
20. Central nervous system complications of HIV.…………………….…..…………………………………..
21. Cognitive and other mental disorders associated with HIV....…...…..…………………………………..
22. Psychological factors affecting HIV medical status .…………………...…………….…………...………
23. Psychopharmacological and drug-drug interactions .….………………………………...…………....….
24. Assessment/diagnosis of neuropsychiatric complications ..…………….………………………………..
25. My ability to respond to client concerns about new HIV treatments …..………………………………..
26. Other
.……………………………………….

27. How will you use what you have learned in this training in your HIV/AIDS work?

28. How could this training be improved?

THANK YOU FOR PARTICIPATING!
To be filled out by education site staff:____ ______ ______ ______ / ______ _____ ___
CMHS Site ID#

Session Number

Date______/______/_____
month

day

year

Participant Feedback Form

Mental Health Care Provider Education in HIV/
AIDS Programs; Substance Abuse and Mental
Health Services Administration (SAMHSA)/Center
for Mental Health Services (CMHS)

This survey will help us evaluate and improve the training program.
Completion of the feedback form is voluntary.

Form Approved
OMB No. 0930-0195
Exp. 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 0930-0195. 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.

Instructions: Please respond to the items by filling in the appropriate oval
using a No. 2 pencil, dark blue or black pen.
1. Anonymous Unique Identifier: This permits training
sites to determine if you have attended multiple trainings.
Last 4 digits of social
security number

month

day
Date of Birth

2. Reasons for attending training (Mark the SINGLE BEST
answer):
CMEs/CEUs
Knowledge/skill development
Friend/family with HIV
Other: ____________
Job requirement
3. Gender:

Male

Female

4a. Are you of Hispanic or Latino descent or origin?
Yes
No
4b. Race: (Select one or more)
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
5. How much formal schooling have you received?
(Please choose only ONE)
Less than high school
M.D.
High school/GED
Doctoral Degree (non-M.D.)
Associate Degree
M.D. & Doctoral Degree
Bachelor’s Degree
Other Professional Degree
Master’s Degree
Other: _________
6. What facility BEST describes the primary setting where
you work? (Please choose only ONE)
Academic Institution
Long-term Care Facility
Community Based
Non-hospital Mental
Organization
Health Clinic/Agency
Correctional Facility
Private Practice
Home Health/Visiting
Public Health Agency/Clinic
Hospice
Religious Organization
Hospital Mental Health
Substance Abuse Treatment
Clinic/Unit
Not working
Other Hospital
Other: _________________
Clinic/Unit

Correct

Incorrect

8. Which of the following describe your work at the
facility identified in Item 6 above? (Mark all that apply)
Administrator/Supervisor
Case Manager
Clergy/Pastoral Worker
Counselor
Faculty/Teacher
Health Educator
Nurse (LPN, RN, APN)
Outreach Worker

Physician (not a Psychiatrist)
Psychiatrist
Psychologist
Social Worker (BSW,MSW)
Student
Volunteer/Buddy
Other: ___________

9. Do you provide services directly to HIV-positive individual(s)?
Yes

No

A. If YES, in what capacity? (Mark the SINGLE BEST answer)
Case Manager
Clergy/Pastoral Worker
Counselor
Educator
Nurse (LPN, RN, APN)
Outreach Worker
Psychiatrist

Physician
(not a Psychiatrist)
Psychologist
Social Worker (BSW,MSW)
Student (specify)_______
Volunteer/Buddy
Other: ___________

B. If NO, what is your main job/capacity? (Mark the
SINGLE BEST answer)
Administrator/Supervisor
Clergy/Pastoral worker
Faculty/Teacher
Health Educator

Researcher
Student
Volunteer
Other: ________

10. Do you provide direct services to family members/significant
others of HIV-positive individual(s)?
Yes

No
10 years or more
Between 5-10 years
2-5 years
Less than 2 years
None

11. Please indicate the number of years
that you have provided service in the
following areas:

Direct HIV-related clinical mental
health services (e.g., therapy)………………...
7. Which geographical description BEST describes where this
Other direct services to HIV-positive
facility is located?
individuals (e.g., primary health care).……….
Any other HIV-related assistance to
Urban
Suburban
HIV-positive individuals (e.g., driving
Rural
Not Applicable
PLEASE TURN OVER someone to an appointment)…..……………..

Strongly Agree

For the following questions, select a rating that reflects
your degree of agreement with the statement presented.

Agree
Neutral
Disagree
Strongly Disagree

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

Already willing/capable/comfortable
17. As a result of this training, I am more
comfortable treating and/or caring
for HIV-positive and HIV-affected
individuals…………………………..…….
18. As a result of this training, I am more
willing to treat and/or care for HIVpositive and HIV-affected individuals…..
19. As a result of this training, I am more
capable of treating and/or caring for
HIV-positive and HIV-affected
Individuals………………………….…….

12. This training session was well organized..…..
13. The information/skills training was useful.…..
14. I was satisfied with the training…………….....
15. I would recommend this training to others..…
16. The HIV-positive guest speaker/panel was
important to my training experience
(skip if not applicable to session)…………..

20. My level of prior knowledge of the information/skills
presented at this training was…
Low

Moderate

To a very great extent
To a great extent

High

To some extent

To what extent has this training increased your HIV/AIDS knowledge/skills
in the following areas: (Indicate if topic was not covered in training.)

To a little extent
Not at all

Topic not covered
21. Psychosocial and/or mental health impact of HIV………………………………………………………………………

All Trainings

Special Populations and Issues
22. Legal and ethical issues……………………………………………………………………………………………….......
23. Providing compassionate care to people from different cultures………………………………………………..…….
24. Caring for special populations (e.g., women, gays, lesbians, people with severe mental illness)…………..…….
25. Caring for family and friends of HIV-infected individuals…………………………………………………………..…..

HIV-Related Conditions and Treatment Aspects
26. How HIV affects the body…………………………………………………………………………………………….…....
27. How HIV infection and AIDS are treated…………………………………………………………………………….…..
28. Adherence to treatment……………………………………………………………………………………………..……..
29. Other sexually transmitted diseases……………………………………………………………………………….……..
30. Neuropsychiatric complications of HIV…………………………………………………………………………..……….
31. Psychotropic and other drug interactions……………………………………………………………………….……….

Transmission and Prevention
32. Who is affected by the epidemic…………………………………………………………………………..……………...
33. Approaches for preventing HIV infection…………………………………………………………………….…………..
34. HIV transmission………………………………………………………………………………………….………………..
35. Counseling and testing issues………………………………………………………………………….…………………
36. How substance use is related to HIV and AIDS………………………………………………………….……………..
37. Perinatal transmission issues…………………………………………………………………………….……………….
38. Taking a sexual history…………………………………………………………………………………..………………...
39. Taking a substance use history…………………………………………………………………………...………………
…………………………………….….
40. Other
41. How will you use what you have learned in this training in your HIV/AIDS work?

42. How could this training be improved?
THANK YOU FOR PARTICIPATING!
To be filled out by education site staff:______ ______ ______ ______ / ______ _____ ______
CMHS Site ID#

Session Number

Date_____/____/_______
month

day

year