TTA Post Event For TTA Post Event Form

Training and Technical Assistance (TTA) Program Monitoring

Attachment 2_TTA Post Event Form_1-28-2022

OMB: 0930-0389

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Form Approved

OMB NO. 0930-xxxx

Exp. Date xx/xx/xxxx

Training and Technical Assistance (TTA)
GPRA Post-Event Form–(GPRA-PEF)

Public reporting burden for this collection of information is estimated to average 10 minutes to complete this questionnaire. Send comments regarding this burden estimate or any other aspect of this collection of information to the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57A, 5600 Fishers Lane, Rockville, MD 20857. 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 control number for this project is 0930-xxxx.

Protocol for New GPRA Process for all TTA Programs

The Training and Technical Assistance programs are SAMHSA programs funded with the intent to support community and professional development. A uniform data collection tool will be used by all TTA grantees.

Government Performance and Results Act (GPRA) Post-Event Form (GPRA-PEF):

  • This form will collect information on participant demographics and satisfaction with the TTA event.

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


TTA GPRA Post-Event Form (GPRA-PEF)

Event Name: __________________________________

Please print clearly in the boxes below using blue or black ink. Print only one number or letter in each space. Uppercase letters only. Provide the last 3 digits of your personal zipcode; last 4 digits of your phone number; 2 digit birth year; first 3 letters of preferred name.

Personal Code (please use uppercase letters): Ex. 734036172BRI

Provide unique identifying instructions (12 characters)

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

LAST 3 ZIPCODE LAST 4 DIGITS PH NO. BIRTH YR FIRST 3 PREFERRED NAME




  1. What do you consider yourself to be?

Shape1 Male

Shape2 Female

Shape3 Transgender (Male to Female)

Shape4 Transgender (Female to Male)

Shape5 Gender non-conforming

Shape6 Other (Specify)______________________________

Shape7 Prefer not to answer

  1. Are you Hispanic, Latino/a, or Spanish origin?

Shape8 Yes

Shape9 No

Shape10 Prefer not to answer

[IF YES] What ethnic group do you consider yourself? You may indicate more than one.

Shape11 Central American

Shape12 Cuban

Shape13 Dominican

Shape14 Mexican

Shape15 Puerto Rican

Shape16 South American

Shape17 Other (Specify)_____________

Shape18 Prefer not to answer

  1. What is your race? You may indicate more than one.

Shape19 Black or African American

Shape20 White

Shape21 American Indian

Shape22 Alaska Native

Shape23 Asian Indian

Shape24 Chinese

Shape25 Filipino

Shape26 Japanese

Shape27 Korean

Shape28 Vietnamese

Shape29 Other Asian

Shape30 Native Hawaiian

Shape31 Guamanian or Chamorro

Shape32 Samoan

Shape33 Other Pacific Islander

Shape34 Other (Specify)_____________

Shape35 Prefer not to answer

  1. Do you think of yourself as…

Shape36 Straight Or Heterosexual

Shape37 Homosexual (Gay Or Lesbian)

Shape38 Bisexual

Shape39 Queer, Pansexual, And/Or Questioning

Shape40 Asexual

Shape41 Something Else? Please Specify ___________________________________

Shape42 Prefer not to answer

  1. Please select the best category that describes your community (Select one or more):

Shape43 Metropolitan or Suburban Community (communities located in a city or town)

Shape44 Tribal Community (any American Indian or Alaska Native tribe, band, nation, pueblo, village, or community)

Shape45 Rural or Frontier Community (sparsely populated areas that are geographically isolated from population centers and services, usually has few homes or other buildings, and not very many people)

Shape46 Unknown

Shape47 Another: _______________________

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

Shape48 Less than 12th Grade

Shape49 12th Grade/High School Diploma/Equivalent

Shape50 Vocational/Technical (Voc/Tech) Diploma

Shape51 Some College or University

Shape52 Bachelor’s Degree (For example: BA, BS)

Shape53 Graduate Work/Graduate Degree

Shape54 Other (Specify)____________________________________

Shape55 Prefer not to answer

  1. What is your primary occupation/profession? (Select one):

Shape56 Addictions Professional

Shape57 Psychiatrist

Shape58 Psychologist

Shape59 Counselor/therapist (all types)

Shape60 Social Worker

Shape61 Recovery coach

Shape62 Peer recovery specialist

Shape63 Prevention specialist

Shape64 Case manager/care coordinator

Shape65 Clinical supervisor

Shape66 Faith leader

Shape67 Community Health Worker/Educator/Health Educator

Shape68 Criminal Justice/Law Enforcement Professional

Shape69 Public or Business Administrator

Shape70 Researcher

Shape71 Physician

Shape72 Physician Assistant

Shape73 Pharmacist

Shape74 Nurse/Nurse Practitioner

Shape75 Advance Practice Registered Nurse

Shape76 Midwife

Shape77 Faith Leader

Shape78 Teacher/educator

Shape79 Dentist

Shape80 Student

i. Full-time _____

ii.Part-time (not working) _____

iii.Part-time (working)_____

Shape81 Business owner

Shape82 Rural worker or Farmer

Shape83 Family member/caregiver

Shape84 Retired

Shape85 Another (please specify):

  1. If you are a Student, what is your primary field of study? (If Not a Student SKIP this question)

Shape86 Addiction Medicine

Shape87 Counseling

Shape88 Criminal Justice/Law Enforcement

Shape89 Medicine (general or residency)

Shape90 Nursing (general or registered nurse)

Shape91 Nursing Practitioner

Shape92 Peer or Recovery Specialist

Shape93 Pharmacy

Shape94 Physician Assistant

Shape95 Prevention science

Shape96 Psychiatry

Shape97 Psychology

Shape98 Public Health (Master’s or PhD)

Shape99 Recovery Coach

Shape100 Social Work

Shape101 Certification program

Shape102 Another (please specify): _____________________________________

  1. Which of the following best describes your principal employment setting? (Select one):

Shape103 State/county/jurisdiction/territorial/tribal government

Shape104 Substance use disorder treatment program

Shape105 Substance use prevention program

Shape106 Community recovery support program

Shape107 Group home

Shape108 Transitional/supported living facility

Shape109 Mental health clinic or treatment program (Community mental health program)

Shape110 Community health/Community health coalition

Shape111 Community coalition

Shape112 Primary care

Shape113 Federally Qualified Health Centers (FQHC)

Shape114 Hospital

Shape115 State or private psychiatric hospital

Shape116 Aging Services Network

Shape117 Skilled nursing facility

Shape118 Criminal justice/corrections (court, prison, jail, prison/probation, TASC)

Shape119 Military/VA

Shape120 Higher education setting

Shape121 Elementary or secondary education setting

Shape122 Community-based organization (including faith-based organizations)

Shape123 Self-employed (any type of business)

Shape124 Farm or rural establishment

Shape125 Family-run or consumer-run organization

Shape126 Homecare

Shape127 Shelter

Shape128 Government

Shape129 Other (please specify):

  1. What is the ZIP Code of your principal employment setting or school (if you are a student)?

Shape130

  1. How satisfied were you with the overall quality of this event?

Shape131 Very Satisfied

Shape132 Satisfied

Shape133 Neutral

Shape134 Dissatisfied

Shape135 Very Dissatisfied

  1. I expect this event to benefit me and/or my community.

Shape136 Strongly Agree

Shape137 Agree

Shape138 Neutral

Shape139 Disagree

Shape140 Strongly Disagree

  1. If you are a practicing healthcare provider, counsellor, preventionist, social worker, educator or work in the criminal justice/law enforcement field (if not SKIP this question) I expect this event will improve my ability to work effectively.

Shape141 Strongly Agree

Shape142 Agree

Shape143 Neutral

Shape144 Disagree

Shape145 Strongly Disagree

  1. I would recommend this event to a friend/colleague.

Shape146 Yes

Shape147 No



Open ended questions

  1. What about the event was most useful to you? ____________________________________

  2. How could this event be improved? _____________________________________________



Thank you for completing our survey.

Return your survey to the Survey Administrator for your Session.





File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleTechnology Transfer Center (TTC) GPRA Post-Event Form
SubjectPost-Event form for the Technology Transfer Center (TTC) network
AuthorSubstance Abuse and Mental Health Services Administration (SAMHS
File Modified0000-00-00
File Created2022-09-12

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