Form GIS

OMB No. xxxx-xxxx

Expiration Date: xx/xx/201x

Attachment 5

CHILDREN’S MENTAL HEALTH INITIATIVE

NATIONAL SYSTEM OF CARE EXPANSION EVALUATION

Group COLLABORATION EVENTs FOR Geographic Information Systems ANALYSIS

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 0930-03xx.  Public reporting burden for this collection of information is estimated to average 15 minutes per respondent, per response, 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 2-1057, Rockville, Maryland, 20857.

Attachment 5a

CMHI SOC Expansion Evaluation: Group Collaboration Events for GIS ANALYSIS

Purpose

The purpose of this Geographic Information Systems Analysis is to understand the geographic spread of individuals involved in Systems of Care Expansion events including but not limited to meetings and trainings. The data will include basic information on the event as well as a list of participants, their organization, and the work address. The address information will be converted to census block group for analysis.

Data collection method and respondents

The event and address information will be provided by the grantee administrator or project directors for the Jurisdiction level and local community administrators or project directors using a form developed by the National Evaluation Team (NET). The NET will request that the forms should be submitted quarterly for all events during the quarter. However, grantees may choose to submit them after each event.

Attachment 5b

INFORMED CONSENT

The Group Collaboration Events for GIS Analysis Form collects data on addresses of participants in Systems of Care related events. As part of the registration process for the group events, a grantee already collects attendee information in terms of their names, affiliation, and address. Grantees will be trained and encouraged to inform the attendees of their plans to share this information with the National Evaluation Team (NET). Grantees and attendees have the option to not provide this information.

Attachment 5c

CHILDREN’S MENTAL HEALTH INITIATIVE

NATIONAL SYSTEM OF CARE EXPANSION EVALUATION

Group Collaborative Events for Geographic Information Systems ANALYSIS Form

INTRODUCTION

Thank you for your willingness to participate in the Geographic Information Systems Analysis portion of the National Systems of Care Expansion Evaluation. The purpose of this data collection is to understand the geographic spread of individual involved in Systems of Care expansion efforts.

CONFIDENTIALITY/INFORMED CONSENT

This form was developed by the National Evaluation Team.

The purpose of this data collection is to understand the geographic spread of individual involved in Systems of Care expansion efforts. Participants in Systems of Care events are asked to provide their work for individuals. The address data will be converted to Census Block group identifiers and mapped to view the geographic areas represented by the participants.

Your participation is completely voluntary.  You have the right to not include your information on this form.

In any of our reports, all responses will be combined so that addresses and participation will never be attributed to your name.

By submitting this form you are indicating that you have read the description of the tool above and that you agree to participate.

[] Agree to Participate

If you have any questions, please contact the National Evaluation Team at cmhieval@westat.com

INSTRUCTIONS

This form is to collect geographic data on participants in Systems of Care Expansion group including but not limited to meetings, training, and collaboration sessions, held at both the Jurisdictional and local level systems service level. For each event, please answer the questions about the type of event held and add the names and work addresses for the persons who attended the event. The addresses will be de-identified and converted by the National Evaluation Team to census block group for analysis. The forms should be submitted to the National Evaluation Team quarterly. However, you may submit the forms after each event.

Attachment 5d

Group Collaborative Events for GIS Analysis Form

Grantee Name:_______________________ Grant ID:_______________________________

Type of Event:

Strategic Planning Meeting

Periodic Update/Status Meeting

Training

Learning Network

Community of Practice Meeting

Conference

Summit

Other

Name of Meeting: __________________________________

Location (Full address): ______________________________

Meeting Date/s: _____________________________________

Meeting Time: _______________________________________

Host/Sponsor: _______________________________________

Meeting Media:

Virtual - Teleconference (phone only)

Virtual - Online (audio/visual)

In Person

Combination (in-person and virtual)

Other

Summary Description (Purpose, Theme, and Content of Meeting):

Attendee Listing:

Name and Title of Attendees	Organizational Affiliation of Attendees
	Organization
	Address
	Organization
	Address
	Organization
	Address
	Organization
	Address
	Organization
	Address

End of Instrument:

Thank you for participating in the GIS study. We appreciate your time and participation.

Attachment 5 – Group Collaboration Events for GIS Analysis Page 2