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
Adolescent SBIRT (A-SBIRT) In-Person Training Feedback Survey:
A-SBIRT 3 month Usage Feedback Survey
Thank you for completing an Adolescent Screening, Brief Intervention and Referral to Treatment (A-SBIRT) training three months ago.
The purpose of this survey is to assess the utilization of the information and skills taught in this course during the past three months.
Your participation is voluntary and your responses will be kept confidential.

1. Please indicate the type of organization with which you are associated.
Federally Qualified Health Center (FQHC)
Pediatric Practice
Prevention Agency
School Based Health Center/School Nurse
Youth Serving Community-Based Organization
Other (please specify)

2. For the past three month period, please indicate approximately how many times you have
used Adolescent SBIRT with girls ages 12-18.

3. For the past three month period, please indicate approximately how many times you have provided a
brief intervention to girls ages 12-18 as part of an Adolescent SBIRT screening.

4. For the past three month period, please indicate approximately how many times you have provided a
referral to treatment to girls ages 12-18 as part of an Adolescent SBIRT screening.

5. Please indicate the most valuable skills or knowledge gained from the Adolescent SBIRT training you
attended three months ago.

6. Please provide any additional comments you wish to share about the Adolescent SBIRT training that you
attended three months ago.

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. Your responses are valued and will help guide this training initiative.