Focus Group Information Form

OMB No.: xxxx-xxxx

Expiration Date: xx/xx/xxxx

Evaluation of NHE Demonstration Grants to Address the Opioid Crisis

Focus Group Participant Information Form

Service Provider/Program/Site (facilitator pre-populates):

INSTRUCTIONS: Please answer each question below. The information you and others provide will be used to document the characteristics of people who participate in this focus group and the services they received. Please do not include your name.

1. Are you:

MARK ALL THAT APPLY

1 □ Currently in recovery from an opioid use disorder

² □ A family member of someone directly affected by the opioid crisis

³ □ In training to become an addiction worker or healthcare provider

⁴ □ An addiction worker or healthcare provider receiving training to better address opioid use disorder

⁵ □ Other (specify) ____________________________________

2. How did you hear about the program?

MARK ONE ONLY

Referred by:

1 □ Employer

2 □ Staff at an American Job Center

3 □ Healthcare provider

4 □ Treatment/recovery provider

5 □ Criminal justice system (for example, a judge, parole or probation officer, reentry specialist)

6 □ Other (specify) __________________________________________________________________

If you were not referred, how did you find out about this program?

From:

7 □ Advertisement

8 □ Family, friends, or others in your community

9 □ Other (specify)

3. About how long have you been participating in this program?

| | | months

4. Which of the types of support have you received through this program?

MARK ALL THAT APPLY

1 □ Help or support training for a new career

2 □ Help or support getting training to advance in my career

3 □ Help or support finding a job

4 □ Help or support preparing a resume

5 □ Help or support applying for a job

6 □ Help or support preparing for or attending a job interview

7 □ Help or support talking with employers your need for workplace accommodations or support

8 □ Help or support solving problems that arise on the job

9 □ Help or support to think about how to advance your education or career (for example, to get a GED, attend college, plan a longer term career path, advocate for raises or promotions, make job changes consistent with your career goals)

10 □ Referral to other services or supports (specify)

11 □ Other (specify)

5. How many years of work experience do you have? (For example: “About 10 years” or “A few months”)

6. Are you working now?

1 □ Yes

0 □ No

7. If you are working now, what is your current job or position?

8. If you are not working now, when was the last time you held a job?

| | | month | | | | | year

9. What type of job or position are you seeking or do you plan to seek?

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

Mark one only

1 □ Less than high school

2 □ High school diploma or equivalent

3 □ Some college

4 □ Associate’s degree or vocational degree

5 □ Bachelor’s degree

6 □ Master’s degree or higher

11. What is your gender?

Mark one only

1 □ Female

2 □ Male

3 □ Non-binary/ third gender

4 □ Prefer to self-describe (specify)

5 □ Prefer not to say

12. What is your age?

Mark one only

1 □ Less than 25 years

2 □ 25-30 years

3 □ 31-40 years

4 □ 41-50 years

5 □ Over 50 years

13. Are you Hispanic or Latino?

1 □ Yes

0 □ No

14. What is your race?

Mark All That Apply

1 □ American Indian or Alaska Native

2 □ Asian

3 □ Black, African American

4 □ Native Hawaiian or other Pacific Islander

5 □ White

6 □ Other (specify)

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, complete the form, and review your answers. 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.

1