Adolescent SBIRT (A-SBIRT) In-Person Training Feedback Surveys: a) Satisfaction and Retrospective Knowledge and Awareness Survey b) A-SBIRT 3 month/6 month Usage Feedback Survey(s)

OMB No. 0990-0379
Exp. Date 09/30/2020
Wheeler Clinic, Inc. Prevention of Opioid Misuse in Women:OWHPA
Connecticut Opioid Misuse Prevention (COMP) Initiative

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Adolescent SBIRT for Girls In-PersonTraining Feedback Survey:
Satisfaction and Retrospective Knowledge and Awareness Survey
Date: ___________________
Please indicate the type of organization with which you are associated (select only one).

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Federally Qualified Health Center (FQHC)
Prevention Agency

Pediatric Practice
School Based Health Center/School Nurse

Youth Serving Community-Based Organization

Other________________________________________________
Please select the best response to each statement.
1. The overall quality of the training (content, speaker, etc.).

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Excellent

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Very Good

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Good

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Fair

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Poor

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Fair

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Poor

2. The quality of the handouts distributed at the training.

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Excellent

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Very Good

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Good

3. The trainers explained the objectives of the training.

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Strongly Agree

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Agree

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Neutral

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Disagree

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Strongly Disagree

4. The trainers provided adequate answers to questions posed by the audience members.

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Strongly Agree

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Agree

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Neutral

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Disagree

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Strongly Disagree

5. The subject of the training was relevant to my work.

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Strongly Agree

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Agree

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Neutral

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Disagree

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Strongly Disagree

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Neutral

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Disagree

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Strongly Disagree

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Disagree

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Strongly Disagree

6. The training objectives were met.

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Strongly Agree

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Agree

7. I feel confident assesing girls ages 12-18 for substance use.

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Strongly Agree

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Agree

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Neutral

8. Before taking this Adolescent SBIRT for Girls training, my answer to #7 would have been:

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Strongly Agree

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Agree

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Neutral

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Disagree

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Strongly Disagree

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Strongly Disagree

9. I feel confident providing a brief intervention to girls ages 12-18 if needed.

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Strongly Agree

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Agree

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Neutral

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Disagree

10. Before taking this Adolescent SBIRT for Girls training, my answer to #9 would have been:

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Strongly Agree

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Agree

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Neutral

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Disagree

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Strongly Disagree

Disagree

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Strongly Disagree

11. I feel confident referring girls ages 12-18 to treatment if needed.

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Strongly Agree

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Agree

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Neutral

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12. Before taking this Adolescent SBIRT for Girls training, my answer to #11 would have been:

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Strongly Agree

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Agree

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Neutral

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Disagree

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Strongly Disagree

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Strongly Disagree

13. I understand the unique risk factors of girls ages 12-18 regarding substance use.

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Strongly Agree

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Agree

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Neutral

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Disagree

14. Before taking this Adolescent SBIRT for Girls training, my answer to #13 would have been:

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Strongly Agree

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Agree

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Neutral

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Disagree

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Strongly Disagree

15. Please use this space for additional comments and suggestions.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0990-0379. The time required to complete this information
collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data
needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate (s) or suggestions for
improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E,
Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Thank you for completing this survey!

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