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CMHIS 60-Day Evaluation Survey: Consultation – Targeted & Intensive

FINAL: CMHIS 60-Day Eval - Consultation - Targeted & Intensive
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CMHIS Evaluation Survey: Consultation - Targeted & Intensive
60-day follow-up survey

Form Approved
OMB NO. 0930-0389
Exp. Date 07/31/2028

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 0930-0389.

Event Name:

This questionnaire aims to gather your feedback regarding the actions you or your organization might have taken as a result of participating in event. The information you provide will be used to enhance and improve future training events. Your answers will not be released to anyone and will remain anonymous. Your name will not be written on the questionnaire or be kept in any other records. All responses you provide for this study will remain confidential.

When the results of the questionnaire are reported, you will not be identified by name or any other information that could be used to infer your identity. Only SAMHSA and its grantee will have access to view any data collected. Your participation is voluntary, and you may withdraw from completing this questionnaire at any time you wish or skip any question you don’t feel like answering.

Your refusal to participate will not result in any penalty or loss of benefits to which you are otherwise entitled.

1. Prior to participating in this event, I felt there was a need for me, my organization, and/or my community to make a change related to the topic of the event.
2. The information from this event has benefited or met a need for me, my family and/or community.
3. The information from this event has benefited me professionally.
4. I have used the information gained from this event to make changes in my practice or to help my family and/or my community.
5. I expect to continue using the information from this event in the future.
6. I have shared the information gained from this event with my family, community, or colleagues.