Form Service_Provider_F Service_Provider_Feedback_Form

Project #

OMB NO. 0930-0270

Expiration Date XX/XX/XXXX

Service Provider Feedback Form

Today’s Date (mm/dd/yyyy)

We are asking that you complete this brief form so that program administrators can learn about your opinions and experiences as an outreach worker, crisis counselor, team leader, or supervisor in the Crisis Counseling Assistance and Training Program (CCP). Do not put your name on this survey. We want you to feel completely free to express your opinion. Thank you for your participation!
The first set of questions is about CCP training. First, please indicate whether you have had each type of training. Then, for each training you have completed, please rate the usefulness of the training in preparing you to do your job, using a scale of 1 to 5, where 1 is not at all useful, 2 is slightly useful, 3 is moderately useful, 4 is very useful, and 5 is extremely useful.
Type of training	Have you had this training?			If YES, please rate the usefulness of this training in preparing you to do your job.
	NO	YES		Not at All Useful (1)	Slightly Useful (2)	Moderately Useful (3)	Very Useful (4)	Extremely Useful (5)
Core Content Training
Transition to Regular Services Program (RSP) Training	NO	YES
Midprogram Training	NO	YES
Disaster Anniversary Training	NO	YES
RSP Phasedown Training	NO	YES
Training on how to complete the CCP evaluation tools (e.g., logs, Weekly Tally Sheet)	NO	YES
Other crisis counseling trainings offered by the state or your agency (e.g., self-care, Skills for Psychological Recovery)	NO	YES

Using a scale of 1 to 5, where 1 is extremely poor, 2 is poor, 3 is fair, 4 is good, and 5 is excellent, please rate each item below. These items relate to other things that can influence your work, such as supervision and support.
				Extremely Poor (1)	Poor (2)	Fair (3)	Good (4)	Excellent (5)
Quality of the supervision provided to you
Opportunities to interact with other staff in supportive ways
Support and training provided to help you avoid compassion fatigue or to cope with the stress of listening to and helping others
Opportunities for professional and personal growth
Appropriateness of the workload (i.e., neither too much nor too little)

PLEASE ALSO ANSWER QUESTIONS ON THE NEXT PAGE.

Adequacy of the resources and tools you had available to do your job	(1)	(2)	(3)	(4)	(5)
How well you understood how your job fit into the bigger picture of your community’s response to the disaster
How well data from the evaluation were shared with crisis counseling teams or used to inform their work
How well you believe the types of services provided by the project matched the types of need present in the community
The overall quality of services provided by the project
How likely you would be to recommend this project to a friend or family member if he or she had the need
For the questions below, please share your reactions (feelings, emotions, and thoughts) about the disaster, considering your reactions in THE PAST MONTH. Using a scale of 1 to 5, where 1 is not at all, 2 is a little bit, 3 is somewhat, 4 is a quite a bit, and 5 is very much, in the past month to what extent . . .
	Not at All	A Little Bit	Somewhat	Quite a Bit	Very Much
Have you had difficulty handling other stressful events or situations due to your crisis counseling work or your reactions to it?	(1)	(2)	(3)	(4)	(5)
Has the crisis counseling work or your reaction to it interfered with how well you take care of your physical health (e.g., eating poorly, not getting enough rest, smoking more, drinking more)?
Has the crisis counseling work or your reaction to it interfered with your ability to work or carry out your other daily activities, such as housework or schoolwork?
Has your crisis counseling work or your reaction to it affected your relationships with your family or friends or interfered with your social, recreational, or community activities?
Have you been distressed or bothered about your reactions?
If you would like to speak with a counselor about your reactions or if you have concerns about your answers to these questions, please call xxx-xxx-xxxx.

The following questions ask about your thoughts on the format you used to complete some of the data collection forms.

PLEASE CONTINUE ON THE NEXT PAGE.

On average, how long did you take to complete one ________ in PAPER FORMAT?

	1–2 minutes (1)	3–4 minutes (2)	5–6 minutes (3)	7–8 minutes (4)	9–10 minutes (5)	11 minutes or more (6)	NA (7)
Individual/Family Crisis Counseling Services Encounter Log
Group Encounter Log
Adult Assessment and Referral Tool
Child/Youth Assessment and Referral Tool

On average, how long did you take to complete one ________ in MOBILE FORMAT? Do not include the time to upload the form.

	1–2 minutes (1)	3–4 minutes (2)	5–6 minutes (3)	7–8 minutes (4)	9–10 minutes (5)	11 minutes or more (6)	NA (7)
Individual/Family Crisis Counseling Services Encounter Log
Group Encounter Log
Adult Assessment and Referral Tool
Child/Youth Assessment and Referral Tool

For PAPER FORMATS, when did you most often complete these forms after the encounter?

	Immediately after (1)	By the end of the day (2)	Within a week (3)	More than a week (4)	NA (5)
Individual/Family Crisis Counseling Services Encounter Log
Group Encounter Log
Adult Assessment and Referral Tool
Child/Youth Assessment and Referral Tool

For MOBILE FORMATS, when did you most often complete these forms after the encounter?

	Immediately after (1)	By the end of the day (2)	Within a week (3)	More than a week (4)	NA (5)
Individual/Family Crisis Counseling Services Encounter Log
Group Encounter Log
Adult Assessment and Referral Tool
Child/Youth Assessment and Referral Tool

Did you use the offline feature for the mobile form? The offline feature allows you to collect data in an offline mode and then upload data to the server once the device is connected to the Internet.
	Not applicable; I did not complete a mobile form		No; I did not understand how to use this feature
	Yes		Other; please specify:
	No; I have not had the need to use this feature

PLEASE CONTINUE ON THE NEXT PAGE.

If you DID NOT use the mobile form, what prevented you from using it? (Select all that apply.)
	Not applicable; I used the mobile form		Not comfortable with technology
	No access to mobile device		Privacy concerns
	Did not understand how to use		Other; please specify:

Were you able to understand the instructions for filling out the forms?
	Yes
	No; please specify issue:

These final questions will help us to describe the total group of people who completed this survey.

How many hours of crisis counseling program work do you do in a typical week?

Less than 20 hours

20–29 hours

30–39 hours

40 or more hours

How many months have you worked with the crisis counseling program? (If less than 1 month, please enter 0.)

Do you supervise the work of other crisis counselors?

No

Yes

In what county or parish do you commonly work?

How do you identify yourself?				Male Female
In what year were you born?
What is the highest level of education you have completed or degree you have received?
	No high school			High school, but no diploma or GED						GED or other high school equivalency
	High school diploma			Some college, but no degree						Associate’s degree (e.g., A.A., A.S.)
	Bachelor’s degree			Graduate or professional degree (e.g., M.A., Ph.D., M.D., J.D.)
Are you Hispanic/Latino?			No			Yes

Which of the following best describes your race? (Please select all that apply.)
	Asian or Pacific Islander		American Indian or Alaska Native		Black or African American
	White or Caucasian		Native Hawaiian

PLEASE CONTINUE ON THE NEXT PAGE.

Do you have any comments you would like to share? If so, please use the box below.

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 Office of Management and Budget (OMB) control number. The OMB control number for this project is 0930-0270. Public reporting burden for this collection of information is estimated to average 15 minutes per participant, 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, MD 20857.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Administrator
File Modified	0000-00-00
File Created	2021-01-24