Post Event Form - Post Event Form - International

Protocol for New GPRA Process for all International TTCs

 

The International TTCs will use uniform data collection tools.

 

GPRA Post-Event Form - International (GPRA- PEF-I):

·         This form will collect information on participant demographics and satisfaction with the TTC event.

·         The GPRA-PEF-I will be used for all events (training, technical assistance, and meetings) regardless of the length of the event.

 

GPRA Follow-up Form - International (GPRA-FU-I): (aka the 30-day follow-up)

·         This form will collect follow-up data for events lasting at least three hours (or more) in length.

·         This form will collect information on application and usefulness of the information gained during the TTC event.

 

 

OMB No. 0930-03xx

Expiration Date: xx/xx/2020

Burden Statement: This information is being collected to assist the Substance Abuse and Mental Health Services Administration (SAMHSA) for the purpose of program monitoring of the Technology Transfer Centers (TTC) Network Program. This voluntary information collected will be used at an aggregate level to determine the reach, consistency, and quality of the TTC Program. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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 Office of Management and Budget (OMB) control number. The OMB control number for this project is 0930-03xx. Public reporting burden for this collection of information is estimated to average less than 10 minutes per encounter, 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 Ln, Room 15 E57B, Rockville, MD 20857.

GPRA Post-Event Form - International (GPRA-PEF-I)

Event Name: _____________

Please enter your unique personal code according to the instructions provided by the survey administrator. Print only one number or letter in each square. Upper case letters only.

1. Do you currently describe yourself as male, female, or transgender?

   1. Female

   2. Male

   3. Transgender

   4. None of these

2. What is the highest degree you have received? (Select one):

   1. Less than high school

   2. High school diploma or equivalent (GED)

   3. Some college, but no degree

   4. Associate’s degree

   5. Bachelor’s degree

   6. Master’s degree

   7. Doctor of Pharmacy (PharmD)

   8. Doctor of Medicine or Doctor of Osteopathy

   9. Other Doctoral degree or Equivalent (e.g., PhD, EdD, DPT)

   10. Other, please specify:

3. What is your primary profession? (Select one):

   1. Clinical – Clinical professionals, including doctors, nurses, midwives, clinical officers, medical and nursing assistants, auxiliary nurses, auxiliary midwives, testing and counseling providers. (Note: You should have completed a diploma or certificate program according to a standardized or accredited curriculum and support or substitute for university-trained professionals.)

   2. Clinical support – Pharmacists, pharmacy technicians, medical technicians, laboratorians, laboratory technicians.

   3. Managerial – Facility administrators, human resource managers, monitoring and evaluation advisors, epidemiologists and other professional staff critical to health service delivery and program support.

   4. Social Service – Social workers, child and youth development workers, social welfare assistants

   5. Lay – Adherence support, mother mentors, cough monitors, expert clients, lay counselors, peer educators, community health workers and other community-based cadres. (Note: Lay workers are those who have nonclinical training and provide services directly to clients. They are health workers who provide important services for the continuum of care within facilities and/or communities.)

   6. Student:

i. Full time ___

ii. Part-time (not working)___

iii. Part-time (working) _____

7. Other – Please specify: ____________________

4. What is your principal employment setting? (Select the one that best matches your setting):

1. HIV clinic

2. Substance use disorder treatment program

3. Substance use disorder prevention program

4. Community recovery support program

5. Group home or transitional/supported living facility

6. Mental health clinic or treatment program (e.g., Community mental health program)

7. Community health center or primary care center

8. Solo practice

9. Group practice

10. General hospital

11. Psychiatric hospital

12. Skilled nursing facility

13. Criminal justice/corrections (court, prison, jail, prison/probation)

14. Military or veterans’ programs

15. Higher education setting

16. Elementary or secondary education setting

17. Community-based organization (including faith-based organizations)

18. Community coalition

19. Other (please specify):

5. What is the postal code of your principal employment setting?

6. How satisfied are you with the overall quality of this event?

   1. Very Satisfied

   2. Satisfied

   3. Neutral

   4. Dissatisfied

   5. Very Dissatisfied

7. I expect this event to benefit my professional development and/or practice.

   1. Strongly Agree

   2. Agree

   3. Neutral

   4. Disagree

   5. Strongly Disagree

8. I expect to use the information gained from this event to change my current practice.

   1. Strongly Agree

   2. Agree

   3. Neutral

   4. Disagree

   5. Strongly Disagree

9. I would recommend this training to a colleague.

Yes

No

Please re-enter your unique personal code included on the first page of the survey. Print only one number or letter in each square. Upper case letters only.

Thank you for completing our survey.