Attachment I - Web Survey Example

Attachment I

Web Survey Example

Showing OMB Control Number, Expiration Date, and Burden Statement

PAIMI Advisory Council Chair Survey

1. Introduction:

Appendix B
Form Approved
OMB NO.: 0930-XXXX
Expiration Date: MM/DD/YY
See burden statement on last page.

Thank you for helping with the first National Evaluation of the PAIMI Program by completing the following questionnaire. We expect that it will take about 30 minutes to complete this survey. This survey is being conducted by the Human Services Research Institute (HSRI) through a contract with the Substance Abuse and Mental Health Services Administration's Center for Mental Health Services (CMHS) for the first National Evaluation of the PAIMI Program. These surveys will provide information from PAIMI Advisory Councils across states and territories to determine a) to what extent PAIMI programs are supporting the work of PAIMI Advisory Councils, b) factors that influence Council Performance, and c) Council member impressions of the PAIMI Program operations.

Please know that there is not a "right" answer to these questions. Comparing programs with vast differences in structure and funding is challenging. To address this, we as evaluators have included a range of answers to try to address this program diversity. If you find yourself choosing "no" or "don't know" response, please do not feel as if your program is doing anything wrong. Although most questions have a list of responses from which to choose, please feel free to further explain your Council's experience.

Responses are strictly confidential. While the identity of the 20 Protection and Advocacy agencies sampled for this evaluation will be noted in out report, the responses of the PAIMI Advisory Chairs and other respondents will not be shared or revealed.

INSTRUCTIONS:

You have the option to complete this survey on line or in printed form. Whether you are completing this survey on line or printed version, all responses are confidential. If you come to a question that you feel uncomfortable answering, skip it.

On line surveys are automatically delivered into a database when you complete and sign off. If you are completing a printed copy of the survey, please return it to use in the enclosed survey as soon as possible.

If you would like assistance completing this survey, or if you need an interpreter, please contact Elizabeth Pell at the Human Services Research Institute. Elizabeth's phone # is 617-876-0426 x 2307 or email epell@hsri.org. Collect calls will be accepted.

10. Public Burden

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 less than one hour 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 7-1044, Rockville, Maryland, 20857.