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

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

60-Day Consultation – Targeted & Intensive

CMHIS Evaluation Survey: Consultation – Targeted & Intensive

60-day follow-up survey

TTA GPRA 60-day follow-up survey

Form Approved
OMB NO. 0930-0389
Exp. Date 05/31/2025

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.

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.
7. What about the event was most useful in supporting your work responsibilities or your role in your community? (CHECK ALL THAT APPLY)
8. If you are a healthcare provider (professional and paraprofessional healthcare providers, including prevention, addiction and mental health treatment and recovery services from states, local, tribal, or healthcare organizations etc.), what has improved in your organization/practice because of this event? (CHECK ALL THAT APPLY)
9. If you are a student, how has this event impacted you? (CHECK ALL THAT APPLY)
10. If you are a community member, from your observation, what has improved in your community because of this event? (CHECK ALL THAT APPLY)

(End of GPRA Follow-Up Survey)

60-day follow-up CMHIS survey for Consultation

Thank you for participating in the consultation process with CMHIS. We value your input on the support you received. Please complete the additional questions below.

Please rate your level of agreement with each of the following statements about the skills and strategies you learned in the consultation process.
Completely disagree
Disagree
Neither agree nor disagree
Agree
Completely Agree
The consultation enhanced my knowledge in the topic(s) we discussed.
The consultation enhanced my skills in the topic(s) we discussed.
I am confident in my ability to apply the knowledge and skills that I learned in the consultation in my work.
I welcome the use of the strategies I learned in my organization.
The strategies I learned seem applicable to my work.
The strategies I learned seem applicable to my organization.
The strategies I learned seem like a good match for my work.
The strategies I learned seem like a good match for my organization.
The strategies I learned seem implementable in my organization.
I have the necessary support to implement the strategies I learned.
I have used the strategies I learned in my work.
I am implementing the strategies as described in the consultation.
I adapted the strategies to fit my work and/or organization.
I have attended a CMHIS event to learn more about the topic(s) we discussed.
My organization will implement these strategies over the next 1-2 years.