Attachment H_SUPPORT Act Grants_Participant Interview Information Form_draft 2 clean

Attachment H – In-depth Participant Interview Questionnaire

OMB Control No: ____-____

Expiration Date: __/__/____

Participant Interview Information Form

Sub-grantee site (site visitor pre-populates):

INSTRUCTIONS: Please answer each question below. This information will help make sure the research team talks with a variety of people in this program. Please do not include your name.

1. Are you (Please mark all that apply.):

☐ In recovery from a substance use disorder

☐ A family member of someone directly affected by the opioid crisis

☐ In training to become an addiction worker or healthcare provider

☐ An addiction worker or healthcare provider receiving training to better address substance use disorder

☐ Other (specify) ____________________________________

2. What is the highest level of education you have completed? (Please mark one.)

☐ Less than high school

☐ High school diploma or equivalent

☐ Some college

☐ Associate’s degree or vocational degree

☐ Bachelor’s degree

☐ Master’s degree or higher

3. What is your gender? (Please mark one.)

☐ Female

☐ Male

☐ Non-binary/ third gender

☐ Prefer to self-describe (specify)

☐ Prefer not to say

4. What is your age? (Please mark one.)

☐ Less than 25 years

☐ 25-30 years

☐ 31-40 years

☐ 41-50 years

☐ Over 50 years

5. Are you Hispanic or Latino?

☐ Yes

☐ No

6. What is your race? (Please mark all that apply.)

☐ American Indian or Alaska Native

☐ Asian

☐ Black, African American

☐ Native Hawaiian or other Pacific Islander

☐ White

☐ Other (specify) ____________________

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to understand programs that integrate employment and substance use disorder services. Public reporting burden for this collection of information is estimated to average 90 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. 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 number and expiration date for this collection are OMB #: XXXX-XXXX, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Hannah Betesh (Abt Associates); [email protected]