Interview Respondent Info Form

OMB No.: xxxx-xxxx

Expiration Date: xx/xx/xxxx

Evaluation of NHE Demonstration Grants to Address the Opioid Crisis

Respondent Information Form

Participant ID (facilitator pre-populates): _____

1. What agency or organization do you work for?

2. What is your affiliation or current position title?

3. How long have you been employed at your current organization?

| | | years and | | | months

4. How long have you been employed in your current position?

| | | years and | | | months

5. What is your title/role in the NHE Opioid grant project?

6. How many years of experience do you have in the type of work you are doing on the NHE project?

| | | years| | | months

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays an Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is xxxx-xxxx. The time required to complete this collection of information is estimated to average 5 minutes, including the time to review instructions, search existing data resources, gather the data needed and complete and review the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to NAME at xxx-xxx-xxxx or NAME@___.gov and reference the OMB Control Number xxxx-xxxx.

7. Please describe your experience working with individuals with opioid use disorder, including positions or roles you have held and any training or certifications you have received:

_________________________________________

_________________________________________

8. During a typical month, about what percentage of your time is spent on NHE Opioid grant activities/services?

| | | | percent of the time

9. What is the highest level of education you have completed?

Mark one only

1 □ High school diploma or equivalent

2 □ Some college

3 □ Associate’s degree or vocational degree

4 □ Bachelor’s degree

5 □ Master’s degree or higher