Attachment 4 - Questions and Values

Data Collection Questions & Corresponding Values

The following are optional questions and the corresponding values for the collection of demographic data from SAMHSA customers when they either register for an account on SAMHSA’s new product Web site or subscribe to receive SAMHSA email updates.

New Product Web Site Registration

• Organization Name

  • Respondents will answer these questions by typing their organization name into an open-text field.

• Is your interest in substance abuse and mental health professional or personal?

  • Respondents will indicate “Professional” or “Personal” by selecting the appropriate radio button.

  • If a respondent selects the “Professional”’ radio button, the “Organization Type” drop-down menu will offer the following values:

1. Treatment Facility

2. Individual/Group Practice

3. Government Office

4. Nonprofit/Community-based Organization/Coalition

5. School/University

6. Other

• If a respondent selects the “Personal” radio button, the “Requestor Type” drop-down menu will offer the following values:

1. Person Seeking Help

2. Family Member/Friend of Someone Needing Help

3. Co-Worker/Supervisor of Someone Needing Help

• Are you or your organization a current recipient of a SAMHSA grant?

  • Respondents will indicate “Yes” or “No” by selecting the appropriate radio button.

• When respondents select “Yes,” they will be prompted on the next screen to enter their grant number and grantee organization name in open-text fields.

• Yes, I would like to sign up for email updates from SAMHSA to receive the latest on substance abuse and mental health resources.

  • Respondents will click the adjacent checkbox to indicate their interest in receiving regular email updates from SAMHSA. No further action is required.

  • Respondents that are not interested in the email update service do not need to take any action.

Email Update Subscription

• Organization Name

  • Respondents will answer this question by typing the name of their organization into an open-text field.

• State

  • Respondents will select their state of residence from a drop-down menu listing all 50 states and U.S. territories.

• Is your interest in substance abuse and mental health professional or personal?

  • Respondents will indicate “Professional” or “Personal” by selecting the appropriate option from the drop-down menu.

  • If a respondent selects the “Professional” drop-down option, the “Organization Type” drop-down menu will offer the following values:

1. Treatment Facility

2. Individual/Group Practice

3. Government Office

4. Nonprofit/Community-based Organization/Coalition

5. School/University

6. Other

• If a respondent selects the “Personal” drop-down option, the “Requestor Type” drop-down menu will offer the following values:

1. Person Seeking Help

2. Family Member/Friend of Someone Needing Help

3. Co-Worker/Supervisor of Someone Needing Help

• Are you or your organization a current recipient of a SAMHSA grant?

  • Respondents will select “Yes” or “No” from the drop-down menu.

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