Participant Feedba Participant Feedback Form

OMB Number:

Expiration Date:

Public Burden Statement: 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 control number for this project is 0930-XXXX. Public reporting burden for this collection of information is estimated to average .15 hours per respondent, per year, 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, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

Participant Feedback Form¹

Consent to Participate

The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) is sponsoring a multi-site evaluation of the Advancing Wellness and Resilience in Education (AWARE) and Trauma-Informed Services in Schools (TISS) programs. AWARE provides funding to strengthen school-based mental health programs and build partnerships to ensure that students have access and are connected to appropriate and effective behavioral health services. The purpose of the TISS program is to increase student access to trauma support services and mental healthcare by developing innovative activities to link local school systems with local support and mental health systems, including those under the Indian Health Service.

This survey asks questions about your reactions and feedback on the training in which you just participated. The survey will take approximately 10 minutes to complete. Your participation in this survey is completely voluntary, and you can choose not to participate. 

Your survey responses will remain confidential throughout the project and will only be shared in aggregate form without ever attributing specific responses to any individual respondent. Taking part in this survey will cause minimal risk. There are no direct benefits for you as a participant. However, it is hoped that through your participation, your community, including schools and community agencies, will be better able to provide mental health services for all students. Lessons learned in your state may also benefit SAMHSA programs in other parts of the country. 

In appreciation of your participation, you will receive a $10 gift card upon completion of the survey.

If you have questions about this initiative please contact the Project Director, Dr. Colleen Murray, at [email protected]. For questions regarding your rights related to survey participation, you can contact ICF’s Institutional Review Board (IRB) at [email protected].

* Please choose one of the options below and click “next” to confirm:

I have read the above information and I voluntarily agree to participate in this survey.

I have read the above and I DO NOT wish to participate in this survey.

The information from this training I found most useful was [Open text field]

At this training, I wish I received [Open text field]

The learning objectives of this training were met?

Strongly Disagree					Moderately Agree					Strongly Agree
0	1	2	3	4	5	6	7	8	9	10

Existing mastery/competence: Before today’s training, what level of mastery or competence did you have with the information, tools, and/or skills described in the training goals?

Complete beginner					Intermediate					Fully expert
0	1	2	3	4	5	6	7	8	9	10

Post-training mastery/competence: Given what you learned in the training, what do you think your level of mastery or competence with the information, tools, and/or skills described is now?

Complete beginner					Intermediate					Fully expert
0	1	2	3	4	5	6	7	8	9	10

Importance of training goals: In your current role, how important is it for you to master the information, tools, and/or skills described in the training goals?

Not at all important					Moderate importance					Utmost importance
0	1	2	3	4	5	6	7	8	9	10

Trainer credibility: To what extent did you find the trainer credible in terms of being fully competent and having a high level of expertise relevant to helping trainees achieve the training goals?

No credibility					Reasonable credibility					Unsurpassed credibility
0	1	2	3	4	5	6	7	8	9	10

Training organization: Overall, how well organized was the training?

Completely disorganized					Moderately organized					Superbly organized
0	1	2	3	4	5	6	7	8	9	10

Training interest: Overall, did you find that the training held your attention?

Not at all					Reasonably well					Exceptionally well
0	1	2	3	4	5	6	7	8	9	10

Level of impact: What level of impact do you think this training will have on your work (or other context) over the coming months?

None					Moderate					Profound/ enduring
0	1	2	3	4	5	6	7	8	9	10

Type of impact: How will what you learned/gained from today’s training impact…?

	Large Negative Impact	Moderate Negative Impact	Small Negative Impact	No Impact	Small Positive Impact	Moderate Positive Impact	Large Positive Impact
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Insert Training Objective 2	¦	¦	¦	¦	¦	¦	¦
Insert Training Objective 3	¦	¦	¦	¦	¦	¦	¦
Insert Training Objective 4	¦	¦	¦	¦	¦	¦	¦
Insert Training Objective 5	¦	¦	¦	¦	¦	¦	¦

Specific impact: What, specifically, is the major impact you anticipate today’s training will have on your work?

Change from current practice: How different is what you learned in today’s training from how you currently approach your work?

Not at All Different					Moderately Different					Radically Different
0	1	2	3	4	5	6	7	8	9	10

Applying your learning: How confident are you that you will be able to integrate what you learned from today’s training (e.g., new information, tools and/or skills) into your work within the next two months?

Not at All Confident					Moderately Confident					Completely Confident
0	1	2	3	4	5	6	7	8	9	10

THANK YOU

for your feedback!!

1 Based on Impact of Training and Technical Assistance (IOTTA Baseline).

5