National Survey on Community Mental Health Center Cancer
ASSESSMENT OF CANCER PREVENTION SERVICES AT COMMUNITY MENTAL HEALTH CENTERS
CMHC_OMB_SSA_APPENDIX 4_Survey Instruments_080317
Clinical Survey Instrument
OMB: 0920-1229
OMB No. XXXX-XXXX
Expiration Date: XX/XX/20XX
National Survey on Community Mental Health Center Cancer Prevention Activities: Administrator Survey
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 XXXX-XXXX. Public reporting burden for this collection of
information is estimated to average 20 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
CDC Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA
30329; ATTN: PRA (XXXX-XXXX)
OMB No. XXXX-XXXX
Expiration Date: XX/XX/20XX
About the Survey
Your community mental health center (CMHC) has been randomly selected for participation in a study funded by the Division of Cancer Prevention and Control (DCPC) at the Centers for Disease Control and Prevention (CDC) and conducted by Abt Associates. Through this study, we aim to better understand the capabilities of CMHCs to provide cancer prevention and screening services to persons with mental illness, to identify barriers to providing such services, and to propose strategies to addressing these barriers and facilitating such services.
As a part of this study, we are conducting a survey of CMHC administrators. Your participation in this survey will help the CDC better understand the capacity of CMHCs to provide cancer prevention services and the needs of CMHCs for training and resources related to cancer prevention.
Your participation in the survey is voluntary. Your completion of the survey indicates your consent to participate in the study. You may withdraw from the study by deleting responses before submission. Your name or your CMHC’s name will not be included in any papers or reports related to this study. Your name, email address and IP address will be used to track survey completion. However, we will not disclose any information that could identify you, such as your name, telephone number, or email. The research team has procedures in place to protect your confidentiality and minimize risk. All de-identified data from the survey will be provided to the CDC at the end of the study.
The survey should take about 20 minutes to complete.
If you have any questions about the study, please contact Project Director, Sue Pfefferle at [email protected], or at (617) 281-2594, or Brooke Steele at [email protected], or at (770) 488-4261.
Instructions
This survey is intended to be completed by a senior administrator (e.g., CEO or COO) who is knowledgeable about services at your CMHC. A leader of psychiatric services at your CMHC will receive a separate survey.
Please respond to the survey thinking about your entire CMHC. The CMHC that you oversee may include more than one location/practice site that provides mental health services. If you oversee services at multiple practice locations/sites, please answer on behalf of all of those sites wherever possible.
If necessary, you may save the survey and complete it at another time by clicking the link in your email invitation.
Once you complete the survey you should press the submit button. Once you submit the survey, you will not be able to edit your responses.
As you fill out the survey, please consider the following definition of cancer prevention services:
Cancer prevention services are activities implemented to assist individuals/populations to decrease their risk factors and increase their protective factors with the goal of minimizing an individual’s odds of developing cancer and maximizing opportunities for early treatment should cancer occur or reoccur.
Cancer prevention services include:
one-on-one or group education,
routine screening,
screening reminders,
navigation services (peer or other) to increase screening uptake,
smoking cessation interventions,
use of social media to promote smoking cessation, and
early cancer detection.
Examples of Evidence on Cancer Risk Factors |
Examples of Evidence on Cancer Protective Factors |
Smoking |
Not smoking |
Exposure to second-hand smoke |
No exposure to second-hand smoke |
Overweight/Obesity |
Maintaining a healthy weight |
High intake of processed foods with low consumption of fresh produce |
Eating a healthy diet with fresh fruits and vegetables |
Lack of exercise |
Regular exercise |
Exposure to toxins and other environmental hazards |
Living in a healthy environment |
No HPV vaccine (for women) |
HPV vaccine (for women) |
Family history of cancer |
No family history of cancer |
No receipt of routine recommended cancer screenings |
Getting routine recommended cancer screenings |
Lack of physician recommendation for cancer screenings |
Physician recommendation for cancer screenings |
Excessive alcohol consumption |
Abstaining from alcohol |
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 XXXX-XXXX. Public reporting burden for this collection of
information is estimated to average 20 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 CDC Clearance Officer, 1600
Clifton Road NE, MS D-74, Atlanta, GA 30329; ATTN: PRA (XXXX-XXXX)
OMB No. XXXX-XXXX
Expiration Date: XX/XX/20XX
General Health and Wellness Services |
We are first interested in understanding general health and wellness services. The next four questions ask about any services either provided at your CMHC or for which providers at your CMHC refer out to an outside provider or agency, for adults, adolescents, and children. Please click on the button next to each service that applies.
|
Provide
the |
General health screenings |
|
General health education |
|
Primary care |
|
Yoga and other mind/body techniques |
|
Healthy lifestyle education |
|
Mindfulness meditation education and skills building |
|
Trauma services |
|
Physical activity education and support |
|
|
Refer out for the following services? |
General health screenings |
|
Primary care |
|
Medical case management |
|
Healthy lifestyle education |
|
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 XXXX-XXXX. Public reporting burden for this collection of
information is estimated to average 20 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 CDC Clearance Officer, 1600
Clifton Road NE, MS D-74, Atlanta, GA 30329; ATTN: PRA (XXXX-XXXX)
|
Provide the following services? |
General health screenings |
|
General health education |
|
Primary care |
|
Medical case management |
|
Yoga and other mind/body techniques |
|
Healthy lifestyle education |
|
Mindfulness meditation education and skills building |
|
Trauma services |
|
Physical activity education and support |
|
|
Refer outside your CMHC for the following services |
General health screenings |
|
General health education |
|
Primary care |
|
Medical case management |
|
Trauma services |
|
Physical activity education and support |
|
Cancer Prevention Services |
|
High priority |
Somewhat of a priority |
Low priority |
Not on our radar |
Cancer screening |
|
|
|
|
Ensuring that women under 26 have an HPV vaccine |
|
|
|
|
Hepatitis B and C vaccinations |
|
|
|
|
HIV counseling and testing |
|
|
|
|
Metabolic screening |
|
|
|
|
Tracking referrals for cancer screening |
|
|
|
|
Primary care |
|
|
|
|
Substance use disorder screening or SBIRT |
|
|
|
|
Mental health promotion and prevention |
|
|
|
|
We would also like to know about cancer prevention services at your CMHC.
|
High priority |
Somewhat of a priority |
Low priority |
Not on our radar |
Smoking |
|
|
|
|
Exposure to second-hand smoke |
|
|
|
|
Overweight and obesity |
|
|
|
|
Lack of exercise |
|
|
|
|
Exposure to toxins and other environmental hazards |
|
|
|
|
Risky sexual behaviors |
|
|
|
|
Family history of cancer |
|
|
|
|
High intake of processed foods with low consumption of fresh produce |
|
|
|
|
Lack of regular health care |
|
|
|
|
Lack of education on cancer prevention |
|
|
|
|
Excessive alcohol use |
|
|
|
|
Please provide one response for each service for Question 7.
|
Provide the following services? |
Tobacco cessation counseling |
|
Clinical breast exams |
|
Cervical cancer screening (Pap test and high-risk HPV test) |
|
Colorectal cancer screening (fecal occult blood test/fecal immunochemical test kit) |
|
Assessment of family history of cancer |
|
One-on-one counseling to encourage screening |
|
Assessment of health behavior risks |
|
Health coaching to decrease risk factors |
|
Screening reminders |
|
Education on cancer prevention |
|
If no items “Provided” in Q7, GO TO Q10.
Please provide one response for each service for Question 8. By refer out, we mean refer to an outside provider or agency.
|
Refer out for the following services? |
Tobacco cessation counseling |
|
Clinical breast exams |
|
Mammogram |
|
Cervical cancer screening (Pap test and high-risk HPV test) |
|
Colorectal cancer screening (fecal occult blood test/fecal immunochemical test kit) |
|
Colorectal cancer screening (colonoscopy) |
|
Who in your CMHC provides cancer prevention services? (Please check all that apply)
-
Psychiatrist
Psychiatric nurse practitioner
Family nurse practitioner
Non-psychiatrist physician (MD/DO)
Psychologist
Social worker
Professional counselor
Nurse
Health educator
Health navigator
Peer support specialist/peer recovery coach
Other (please specify )
Go to Q11.
(If they are not providing services) Do you anticipate that your CMHC will begin providing cancer prevention services in-house within the next year? (GO to Q12b)
-
Yes
No
(If they are providing any services) Do you anticipate that your CMHC will increase the cancer prevention services it provides in-house within the next year?
-
Yes
No
For what percent of individuals served by your CMHC do you…
|
a. Provide cancer screening directly at your CMHC? By cancer screening we mean services such as clinical breast exams; Pap tests, high-risk HPV testing; or fecal occult blood testing/fecal immunochemical test kit, etc. |
% |
|
||
|
b. Make referrals to primary care providers for cancer screening? |
% |
|
||
|
c. Provide other physical health services directly at your CMHC? |
% |
|
||
|
d. Make referrals to primary care providers for other physical health services? |
% |
|
||
|
Percent |
Don’t Know |
|||
Adults (aged 18 and over) served by your CMHC have a primary care physician? |
% |
|
|||
Children under the age of 18 served by your CMHC have a primary care physician? |
% |
|
|||
My CMHC has the following resources necessary to provide cancer prevention services:
|
Strongly disagree |
Disagree |
Not sure |
Agree |
Strongly agree |
Space |
|
|
|
|
|
Financial resources |
|
|
|
|
|
Staffing |
|
|
|
|
|
Training and education on cancer prevention |
|
|
|
|
|
Other (please describe): ______________________________ |
|
|
|
|
|
|
Please rank your top three priorities |
Training on cancer risks |
|
Training on smoking cessation counseling |
|
Training in specific evidence-based cancer interventions |
|
Training on use of your EHR, if any, to track cancer screenings |
|
Characteristics of your CMHC |
Now we would like to know some background about your CMHC. If your CMHC has more than one site, please answer on behalf of all of those sites.
How many mental health providers, in full-time equivalents (FTEs) based on a 40 hour week, currently work at your CMHC?
Your best estimate is fine. |
FTEs |
Therapists, including: licensed certified social workers (LCSW), licensed independent clinical social workers (LICSW), licensed marriage and family therapists (LMFTs), and licensed mental health counselors (LMHCs) |
|
Peer support specialists |
|
Registered nurses |
|
Psychiatric nurse practitioners (APRNs) |
|
Psychiatrists |
|
Psychologists |
|
Primary care providers (MDs, DOs) |
|
Primary care providers (FNPs, PAs) |
|
Other (please specify):___________________________________________________ |
|
Is your CMHC involved in any of the following primary care/behavioral health integration efforts? (Please check all that apply)
|
Medicaid Health Home under Section 2703 of the Affordable Care Act or planning to become a Health Home |
|
Both a CMHC and FQHC |
|
CMHC is also an FQHC look-alike |
|
CMHC is part of a Patient-Centered Medical Home |
|
SAMHSA Primary Care Behavioral Health Integration grantee CMHC is working toward primary care/behavioral health integration |
|
Other (please specify): |
|
None (If none, GO TO Q19) |
How would you characterize your CMHC’s primary model of mental health care delivery in the context of behavioral health integration?
|
Co-located mental health and primary care services. Mental health and physical health providers are located at a single location but operate as independent organizations (e.g., staffing, billing, and medical records). |
|
Close collaboration onsite with some system integration. Mental health and physical health provider relationships have been built and are leveraged to increase shared patient care. |
|
Full collaboration in a transformed/integrated practice. Mental health and physical health services are fully integrated (e.g., resources are allocated evenly across the entire practice, only one treatment plan exists for all patients to which all providers have access). |
|
Fully integrated teams. Behavioral health and physical health care professionals working in fully integrated treatment teams. |
|
Other (please specify) : ______________________ |
The next two questions ask about services either provided at your CMHC or for which providers at your CMHC refer out to an outside provider or agency. Please click on the button next to each service that applies.
|
Provide the following services? |
Substance use disorder services |
|
Treatment for PTSD |
|
Housing services |
|
Vocational/employment services |
|
Case management |
|
Recovery supports |
|
|
Refer out for the following services? |
Substance use disorder services |
|
Treatment for PTSD |
|
Housing services |
|
Vocational/employment services |
|
Case management |
|
Recovery supports |
|
Do the majority of mental health providers at your CMHC use an electronic health record (EHR) system to document cancer prevention services? Do not include billing record systems. Please select only one answer.
-
Yes, all records in EHR
All electronic, but we use a separate EHR for health services
EHR for health but not mental health services
Part paper and part electronic
No
Who receives services at your CMHC? |
For the following questions about the individuals who receive services at your CMHC, we understand that these are approximate percents and your best estimate is fine.
|
# |
What is the approximate age distribution of the individuals who receive services at your CMHC?
5 years old or younger |
6 to |
13 to |
18 to |
26 to |
65 years old or older |
|
% |
% |
% |
% |
% |
% |
= 100% |
|
% |
What is the approximate racial distribution of the individuals who receive services at your CMHC?
African American/ |
Asian American/ Asian |
White/ Caucasian |
Native American/ |
Some other race/ multiple |
No information available |
|
% |
% |
% |
% |
% |
% |
= 100% |
|
% |
What environmental risk factors do individuals served by your CMHC face?
|
Please rank your top three priorities |
No accessible chain grocery stores |
|
Lack of available social services |
|
Stress due to frequent community violence |
|
Lack of public transportation |
|
Low SES environment |
|
No accessible primary care |
|
Lack of quality housing |
|
Unemployment |
|
Other (please specify): |
|
About You |
Finally, please tell us a little about yourself.
What is your role?
-
CEO or President
CFO or Business Director
Chief Medical Officer
Other, please specify:
How long have you worked at your CMHC, in your present role or another role?
-
0 to 2 years
3 to 5 years
6 to 10 years
More than 10 years
Thank you for taking the time to complete this survey!
May we contact you in the future to discuss cancer prevention in more detail?
-
Yes
No
-
If yes, what is the best email address at which to contact you?
OMB No. XXXX-XXXX
Expiration Date: XX/XX/20XX
National Survey on Community Mental Health Center Cancer Prevention Services: Psychiatric Clinician Survey
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 XXXX-XXXX. Public reporting burden for this collection of
information is estimated to average 15 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 CDC Clearance Officer, 1600 Clifton Road NE, MS D-74,
Atlanta, GA 30329; ATTN: PRA (XXXX-XXXX)
OMB No. XXXX-XXXX
Expiration Date: XX/XX/20XX
About the Survey
Your community mental health center (CMHC) has been randomly selected for participation in a study funded by the Division of Cancer Prevention and Control (DCPC) at the Centers for Disease Control and Prevention (CDC) and conducted by Abt Associates. Through this study, we aim to better understand the capabilities of CMHCs to provide cancer prevention and screening services to persons with mental illness, to identify barriers to providing such services, and to propose strategies to addressing these barriers and facilitating such services.
As a part of this study, we are conducting a survey of CMHC psychiatric clinicians, primarily psychiatrists and psychiatric nurse practitioners. Your participation in this survey will help the CDC better understand the capacity of CMHCs to provide cancer prevention services and the needs of CMHCs for training and resources related to cancer prevention.
Your participation in the survey is voluntary. You are not required to complete the survey. Your completion of the survey indicates your consent to participate in the study. You may withdraw from the study by deleting responses before submission. Your name or your CMHC’s name will not be included in any papers or reports related to this study. Your name, email address and IP address will be used to track survey completion. However, we will not disclose any information that could identify you, such as your name, telephone number, or email. The research team has procedures in place to protect your confidentiality and minimize risk. All de-identified data from the survey will be provided to the CDC at the end of the study.
The survey should take about 15 minutes to complete.
If you have any questions about the study, please contact Project Director, Sue Pfefferle at [email protected], or at (617) 281-2594, or Brooke Steele at [email protected], or at (770) 488-4261.
Instructions
This survey is intended to be completed by a psychiatrist or psychiatric nurse practitioner who is knowledgeable about clinical services at your CMHC. A senior administrator at your CMHC will receive a separate survey.
Please respond to the survey thinking about all mental health care provided at your CMHC. The CMHC where you work may include more than one location/practice site. If you provide services at more than one CMHC site, please answer on behalf of all of those sites.
If necessary, you may save the survey and complete it at another time by clicking the link provided in your email invitation.
Once you complete the survey you should press the submit button. Once you submit the survey, you will not be able to edit your responses.
As you fill out the survey, please consider the following definition of cancer prevention services:
Cancer prevention services are activities implemented to assist individuals/populations to decrease their risk factors and increase their protective factors with the goal of minimizing an individual’s odds of developing cancer and maximizing opportunities for early treatment should cancer occur or reoccur.
Cancer prevention services include:
one-on-one or group education,
routine screening,
screening reminders,
navigation services (peer or other) to increase screening uptake,
smoking cessation interventions,
use of social media to promote smoking cessation, and
early cancer detection.
Examples of Evidence on Cancer Risk Factors |
Examples of Evidence on Cancer Protective Factors |
Smoking |
Not smoking |
Exposure to second-hand smoke |
No exposure to second-hand smoke |
Overweight/Obesity |
Maintaining a healthy weight |
High intake of processed foods with low consumption of fresh produce |
Eating a healthy diet with fresh fruits and vegetables |
Lack of exercise |
Regular exercise |
Exposure to toxins and other environmental hazards |
Living in a healthy environment |
No HPV vaccine (for women) |
HPV vaccine (for women) |
Family history of cancer |
No family history of cancer |
No receipt of routine recommended cancer screenings |
Getting routine recommended cancer screenings |
Lack of physician recommendation for cancer screenings |
Physician recommendation for cancer screenings |
Excessive alcohol consumption |
Abstaining from alcohol |
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 XXXX-XXXX. Public reporting burden for this collection of
information is estimated to average 15 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 CDC Clearance Officer, 1600 Clifton Road NE, MS D-74,
Atlanta, GA 30329; ATTN: PRA (XXXX-XXXX)
General Health and Wellness Services |
We are first interested in understanding general health and wellness services. The next four questions ask about any services either provided at your CMHC or for which providers at your CMHC refer out to an outside provider or agency, for adults, adolescents, and children. Please click on the button next to each service that applies.
|
Provide
the |
General health screenings |
|
General health education |
|
Primary care |
|
Medical case management |
|
Yoga and other mind/body techniques |
|
Healthy lifestyle education |
|
Mindfulness meditation education and skills building |
|
Trauma services |
|
Physical activity education and support |
|
|
Refer out for the following services? |
General health screenings |
|
Primary care |
|
Medical case management |
|
Healthy lifestyle education |
|
|
Provide the following services? |
General health screenings |
|
General health education |
|
Primary care |
|
Medical case management |
|
Yoga and other mind/body techniques |
|
Healthy lifestyle education |
|
Mindfulness meditation education and skills building |
|
Trauma services |
|
Physical activity education and support |
|
|
Refer outside your CMHC for the following services |
General health screenings |
|
General health education |
|
Primary care |
|
Medical case management |
|
Trauma services |
|
Physical activity education and support |
|
We would also like to know about specific cancer prevention services offered at your CMHC.
|
Provide the following services? |
Tobacco cessation counseling |
|
Clinical breast exams |
|
Mammograms |
|
Cervical cancer screening (Pap test and high-risk HPV test) |
|
Colorectal cancer screening (fecal occult blood test/fecal immunochemical test kit) |
|
Colorectal cancer screening (colonoscopy) |
|
Assessment of family history of cancer |
|
One-on-one counseling to encourage screening |
|
Assessment of health behavior risks |
|
Health coaching to decrease risk factors |
|
Screening reminders |
|
If no “Provide” items for Q5, GO TO Q7b.
|
Refer out for the following services? |
Tobacco cessation counseling |
|
Clinical breast exams |
|
Mammograms |
|
Cervical cancer screening (Pap test and high-risk HPV test) |
|
Colorectal cancer screening (fecal occult blood test/fecal immunochemical test kit) |
|
Colorectal cancer screening (colonoscopy) |
|
Assessment of family history of cancer |
|
One-on-one counseling to encourage screening |
|
Assessment of health behavior risks |
|
Health coaching to decrease risk factors |
|
|
|
a. Provide cancer screening directly at your CMHC? By cancer screening we mean services such as clinical breast exams; Pap tests, and high-risk HPV testing; or fecal occult blood testing/fecal immunochemical test kit, etc. |
% |
b. Make referrals to primary care providers for cancer screening? |
% |
c. Provide other physical health services directly at your CMHC? |
% |
d. Make referrals to primary care providers for other physical health services? |
% |
Does your CMHC employ peer wellness coaches?
Yes
No (GO TO Q 10)
We are interested to learn about what peer wellness coaches do at your CMHC. Do clinical staff refer individuals served at your CMHC to peer wellness coaches on a regular basis for…
Health navigation services? |
|
One-on-one coaching to increase uptake of cancer screening? |
|
Support during cancer testing? |
|
Planning wellness goals? |
|
Accompanying individuals to physical health care appointments? |
|
|
% |
Don’t Know |
|
What services, if any, does your CMHC provide to individuals with a diagnosis of cancer?
Health navigation services |
|
Escort to health care visits |
|
Support to help individuals continue routine screening |
|
Assistance in accessing cancer support groups |
|
Other (please describe)_________________________________________ |
|
To what extent do you feel the following providers at your CMHC are equipped to implement cancer prevention services for individuals served by your CMHC?
|
Highly equipped |
Somewhat equipped |
Not very equipped |
Not at all equipped |
Nurses at your CMHC |
|
|
|
|
Therapists (PhDs, LICSWs or LCSWs, LPCs, LMFTs, or LMHCs) at your CMHC |
|
|
|
|
Peer support specialists at your CMHC |
|
|
|
|
Psychiatric clinicians at your CMHC |
|
|
|
|
|
Please rank your top three priorities |
Training on cancer risk factors |
|
Training on smoking cessation counseling |
|
Training in specific evidence-based cancer interventions |
|
Training on use of your EHR, if any, to track cancer screenings |
|
Training on brief motivational interventions |
|
Other (please describe) |
|
Providers at my CMHC have the following resources necessary to provide cancer prevention services:
Strongly disagree
Disagree
Not sure
Agree
Strongly agree
Space
Time
Support staff
Other (please describe):
External Resources
Are you aware of the National Breast and Cervical Cancer Early Detection Program in your state?
|
Yes |
|
No (GO TO Q 17) |
Do you have a partnership with the National Breast and Cervical Cancer Early Detection Program in your state? By partnership we mean a memorandum of agreement or understanding, or an informal agreement to refer women for screening through the program.
|
Yes |
|
No |
Are you aware of the Comprehensive Cancer Control Coalition in your state?
|
Yes |
|
No (Go to Q 19) |
Do you have a partnership with the Comprehensive Cancer Control Coalition in your state? By partnership we mean membership in the coalition, participation in coalition meetings, or a memorandum of understanding or informal agreement with your state’s coalition.
|
Yes |
|
No |
Do psychiatric providers at your CMHC have access to your local health information exchange?
|
Yes |
|
No |
|
Of great concern |
Somewhat of a concern |
Low concern |
Not a concern |
Housing services |
|
|
|
|
Employment services |
|
|
|
|
Substance use disorder services |
|
|
|
|
Detox |
|
|
|
|
Medication-assisted treatment |
|
|
|
|
Primary care |
|
|
|
|
Psychiatry |
|
|
|
|
Characteristics of your CMHC |
Now we would like to know some background about your CMHC. If your CMHC has more than one site, please answer on behalf of all of those sites.
In what languages does your CMHC provide services? (Please check all that apply)
|
English |
|
Spanish |
|
Korean |
|
Mandarin |
|
Szechuan |
|
Arabic |
|
Vietnamese |
|
Farsi |
|
Tagalog |
|
Haitian Creole |
|
Other (please specify): |
About the People Served at the CMHC |
For the following questions about the individuals who receive services at your CMHC, we understand that these are approximate percentages and your best estimate is fine.
|
% |
|
% |
About You |
Finally, please tell us a little about yourself.
Are you…
-
A psychiatrist
A psychiatric nurse practitioner
Other
How long have you worked at your CMHC?
-
0 to 2 years
3 to 5 years
6 to 10 years
More than 10 years
Thank you for taking the time to complete this survey!
May we contact you in the future to discuss cancer prevention in more detail?
-
Yes
No
-
If yes, what is the best email address at which to contact you?
Abt
Associates CDC
Contract 200-2014-61267-0002 December 29,
2016 ▌1-
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Sean McClellan |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |
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