Form Attachment G_Evalu Attachment G_Evalu Attachment G_Evaluation

OMB No. 0930-xxxx

Expiration Date xx/xx/xxxx

Dissemination Evaluation Survey – Coaching Webinar

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 10 minutes 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, One Choke Cherry Road, Room 8-1099, Rockville, Maryland 20857.

Increased efforts are being made by the U.S. Government to improve the dissemination and implementation of evidence-based practices into routine health care. This survey is being conducted as part of a larger study funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) to examine factors that influence an organization’s decision to adopt evidence-based practices.

A short while ago, you participated in a Coaching Webinar for Motivational Interviewing (MI). We are interested in hearing from you regarding this Webinar. Specifically, we want your feedback on the quality of information and presentation, the quality of the Webinar platform, and the overall helpfulness of the Webinar. Your participation in this survey is voluntary. There are no right or wrong answers to the questions. We are interested in what you think. If you are uncomfortable answering a question, you may skip that question. Your responses will be protected under the Federal Privacy Act. Your name and address will be kept in a separate file from your survey responses as a procedural safeguard. No one from your organization will see your answers.

This survey will take approximately 5-10 minutes to complete. Please use the next and back buttons at the bottom of each page to advance forward or go back. Every time you hit the next or back button, your progress is saved automatically. You do not have to complete your survey in one sitting. You can stop your survey and return to complete it at a later time by following the survey link. At the end of the survey you will be asked to submit it. Once it has been submitted, you cannot make any further changes.

I participated in the MI Coaching Webinar

• True

• False

Skip Pattern Programmed Here

I had no difficulty accessing the MI Coaching Webinar

• True

• False

The instructions for using the Webinar software were easy to follow

• True

• False

How satisfied were you with the quality of the information provided during the MI Coaching Webinar?

• Very satisfied

• Somewhat satisfied

• Not satisfied

• No opinion

How would you describe the overall content of the MI Coaching Webinar?

• Too technical

• About right

• Too simple

• No opinion

How satisfied were you with the presentation quality of the overall Webinar (visual, sound, presenter effectiveness)?

• Very satisfied

• Somewhat satisfied

• Not satisfied

• No opinion

Skip Pattern Programmed Here

If you were not satisfied with the quality of the presentation, please provide detail below.

How satisfied were you with the level of interaction during the Webinar?

• Very satisfied

• Somewhat satisfied

• Not satisfied

• No opinion

Skip Pattern Programmed Here

If you were not satisfied with the level of interaction during the Webinar, please provide detail below.

All my questions were answered during the Webinar

• True

• False

I have talked to others at my program about the information from the Webinar

• True

• False

I have shared the Webinar with others in my program (e.g., provided the link to the Webinar content)

• True

• False

Skip Pattern Programmed Here

If you have shared the Webinar with others in your program, identify the role(s) of such person or persons within the program?

Overall, how helpful was the MI Coaching Webinar in helping you to decide whether to implement MI?

• Very helpful

• Somewhat helpful

• Not helpful

• No opinion

What was most helpful about the MI Coaching Webinar?

What was least helpful about the MI Coaching Webinar?

What suggestions do you have to improve the MI Coaching Webinar?

You have reached the end of the survey. If you wish to go back to review and/or change your responses to one or more items, please do so now using the back button below. If you are ready to submit your responses, please click the next button below to advance to the next page. Once you submit your responses, you will not be able to return to the survey. Thank you for your time and participation.

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