Form Provider Survey Provider Survey Provider Survey

Attachment 5:
Provider Survey

OMB No XXXX-XXXX

Exp. Date XX/XX/XXXX

CROSS-SITE EVALUATION OF SAMHSA’S FY 2012 – FY 2015 PORTFOLIO OF COOPERATIVE AGREEMENTS FOR STATE ADOLESCENT AND TRANSITIONAL AGED YOUTH TREATMENT ENHANCEMENT AND DISSEMINATION DISCRETIONARY GRANT PROGRAMS

PROVIDER SURVEY

[SYT-ED/SYT-I] Provider Survey

Today’s Date:
	Mo			Day			Year

Provider Organization Identification Number:

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 XXXX-XXXX. Public reporting burden for this collection of information is estimated to average 1 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, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

Please begin survey on the next page →

INTRODUCTION

The Substance Abuse and Mental Health Services Administration (SAMHSA) has contracted with RTI International and its partners—the University of Arizona’s Southwest Institute for Research on Women (SIROW) and Health and Education Research, Management, and Epidemiologic Services (HERMES), LLC—to conduct a cross-site evaluation of SAMHSA’s portfolio of Cooperative Agreements for State Adolescent and Transitional Aged Youth Treatment Enhancement and Dissemination discretionary grant programs.

You or your organization was identified as a substance abuse service provider that is part of the [Insert Grantee’s SYT-ED/SYT-I Program]. To improve upon and better understand the [SYT-ED/SYT-I] program we would like you to answer the following survey questions. This survey is part of the national evaluation of the SAMHSA-funded [SYT-ED/SYT-I] Program that is being conducted by the RTI team, and it aims to collect data to help identify program activities and services that are being implemented as part of the [SYT-ED/SYT-I] grant program and the impact these activities/services may have on client outcomes and treatment systems.

To best complete these questions, we recommend that an individual most familiar with your organization and its role within the [SYT-ED/SYT-I] program complete this survey. The questions in this survey ask about the services you or your organization provides and your experiences participating in the [SYT-ED/SYT-I] program.

Although we are funded by SAMHSA, we are not part of that federal agency (or any other federal agency). We are independent evaluators of the [SYT-ED/SYT-I] program. Your organization’s name will not appear in any report unless we specifically ask for and receive your approval. The information that you provide is completely voluntary; however, we hope that you will participate as we greatly value any information you can provide.

This survey contains the following modules:

1. organizational background;

2. client population and services provided;

3. project/program implementation activities;

4. sources of funding and outside partnerships; and

5. resources used and costs

The information you provide in this survey should reflect the period from <<insert date>> to <<insert date>>, unless otherwise indicated.

If you have any questions or need assistance in completing this survey, please contact Carolina Holt at cholt@rti.org or 919-316-3561.

Thank you for your participation!

SECTION A: ORGANIZATIONAL BACKGROUND

In this section we are gathering background information about you and your organization.

1. How long have you worked for this organization?

	0–5 months
	6–11 months
	1–2 years
	3–4 years
	5 or more years

2. Were you hired as part of [Grantee’s SYT-ED/SYT-I Program]?

	Yes
	No
	Don’t know

3. Which one of the following job titles best describes your position in this organization? (Please choose only one.)

	Organization director or senior manager
	Program planner
	Program implementation
	Case manager/care coordinator
	Clinical services director
	Other (please specify):

4. Which of the following best describes your organization? (Please check all that apply.)

	Substance use disorder treatment provider
	Co-occurring substance use and mental disorder treatment provider
	Community-based
	Tribal agency
	Indian Health Service provider
	Other (please specify):

5. How would you classify the ownership structure of your organization?

	Private, for-profit
	Private, not-for-profit
	Public, not-for-profit
	Other (please specify):

6. For how many months has/had your organization been involved with the [Grantee’s SYT-ED/SYT-I Program]?

	Months (e.g., If less than 1 month, enter “0”; if 1 month enter “1”; if 2 years, enter “24”; etc.)

7. Is your organization still actively involved with the [Grantee’s SYT-ED/SYT-I Program] as part of its learning laboratory?

	Yes
	No

8. For how many months have you been personally involved with the [Grantee’s SYT-ED/SYT-I Program]?

	Months (e.g., If less than 1 month, enter “0”; if 1 month enter “1”; if 2 years, enter “24”; etc.)

SECTION B: CLIENT POPULATION AND SERVICES PROVIDED

In this section we are gathering aggregate information about the types of clients you serve, and the particular services you offer. As a reminder, the information you provide should reflect the period from <<insert date>> to <<insert date>>.

9. Approximately what percentage of your organization’s clients are served through [Grantee’s SYT-ED/SYT-I Program]?

%

10. Please indicate the client population age groups your organization serves/served through [Grantee’s SYT-ED/SYT-I Program]. (Please check all that apply.)

	Adolescents: age 12 to 18
	Transitional Aged Youth: age 16 to 18
	Transitional Aged Youth: age 18 to 21
	Transitional Aged Youth: age 18 to 24
	Transitional Aged Youth: age 21 to 25
	Other (please specify):

11. Please briefly describe any special populations that are you are targeting because of your involvement with [Grantee’s SYT-ED/SYT-I Program].

12. Approximately what percentage of the clients served through [Grantee’s SYT-ED/SYT-I Program] are diagnosed with substance use disorders only?

	% (e.g., If half of [SYT-ED/SYT-I] clients are diagnosed with substance use disorders only, then enter “50”; etc.)

13. Approximately what percentage of the clients served through [Grantee’s SYT-ED/SYT-I Program] are diagnosed with co-occurring mental health and substance use disorders?

	% (e.g., If half of [SYT-ED/SYT-I] clients are diagnosed with co-occurring mental health and substance use disorders only, then enter “50”; etc.)

14. Approximately what percentage of the clients served through [Grantee’s SYT-ED/SYT-I Program] have family members involved in the treatment and recovery process?

	% of clients with family involved to a great extent
	% of clients with family involved to some extent
	% of clients with little or no family involvement

15. Can you briefly describe how family members are involved in the treatment and/or recovery process?

16. Which of the following types of care are offered by your organization? Please include all types of care offered by your organization, not only those included in the [SYT-ED/SYT-I] program. (Please check all that apply.)

• Day treatment

• Inpatient/hospital (other than detox)

• Outpatient, non-methadone

• Outreach

• Intensive outpatient

• Residential/rehabilitation

• Detoxification

• Aftercare

• Recovery support services (including case management services)

• Other (please specify): ______________________________

17. Which specific clinical treatment and/or medical services does your organization provide as part of the [SYT-ED/SYT-I] program? (Please check all that apply.)

• Outreach and engagement

• Screening

• Detoxification

• Crisis intervention

• Assessment

• Treatment planning

• Case management

• Substance abuse counseling

• Substance abuse education services

• Trauma services

• Medical care

• Pharmacotherapy/Medication assisted treatment

• Mental health services

• Drug monitoring

• Continuing care

• Other (please specify): ______________________________

18. Which specific recovery support services does your organization provide as part of the [SYT-ED/SYT-I] program? (Please check all that apply.)

• Peer-to-peer support

• Parent/family/caregiver support

• Youth and caregiver respite care

• Technology support services

• Therapeutic mentors

• Behavioral health consultation

• Vocational, educational, and transportation services

• Child care

• Other (please specify):

19. Do the services offered by your organization to [SYT-ED/SYT-I] funded clients differ from those services offered to clients not funded through the [SYT-ED/SYT-I] program?

• Yes

• No

• Don’t know

19a. If yes, please describe how service offerings differ between [SYT-ED/SYT-I] funded clients and clients not funded through the [SYT-ED/SYT-I] program.

20. For the period from <<insert date>> to <<insert date>>.what was your organization’s…

Total number of enrolled clients through [Grantee’s SYT-ED/SYT-I Program]?
Number of clients typically served daily through [Grantee’s SYT-ED/SYT-I Program]?
Total number of admissions through [Grantee’s SYT-ED/SYT-I Program]?
Number of new admissions?
Number of readmissions?
Average length-of-stay (in weeks) for clients served through [Grantee’s SYT-ED/SYT-I Program]?
Percentage of SYT-ED/SYT-I clients with: private insurance coverage
Medicaid/CHIP coverage
other public insurance coverage
No Insurance

SECTION C: PROJECT/PROGRAM IMPLEMENTATION ACTIVITIES

In this section we are gathering information about activities in which your organization has engaged in as part of implementing your [SYT-ED/SYT-I] project/program. As a reminder, the information you provide should reflect the period from <<insert date>> to <<insert date>>.

21. Which type of evidence-based screening(s)/assessment(s) is your organization implementing for the [Grantee’s SYT-ED/SYT-I Program]? (Please check all that apply.)

• Comprehensive Adolescent Severity Inventory (CASI)

• Teen Addiction Severity Index (T-ASI)

• Global Appraisal of Individual Needs (GAIN-I)

• GAIN Lite

• GAIN SS

• GAIN Q3

• Other (please specify): _________________________

22. Which type of evidence-based treatment approach(es) is your organization implementing for the [Grantee’s SYT-ED/SYT-I Program]? (Please check all that apply.)

• Family Support Network (FSN)

• The Seven Challenges

• Multidimensional Family Therapy (MDFT)

• Adolescent Community Reinforcement Approach (A-CRA)

• Brief Strategic Family Therapy

• Family Behavior Therapy

• Parenting with Love and Limits (PLL)

• Multisystemic Therapy (MST) for Juvenile Offenders

• Chestnut Health Systems – Bloomington Adolescent Outpatient (OP)

• Intensive Outpatient Treatment Model

• Other (please specify): _______________________

23. Have your staff received any training related to the [SYT-ED/SYT-I] program to help you with any aspect of implementing your [SYT-ED/SYT-I] project/program?

• Yes

• No, go to Question 27

• Don’t know, go to Question 27

23a. If yes, please indicate the type of training they received. (Please check all that apply.)

• Evidence-based screening/assessment

• Evidence-based treatment

• Trauma-informed services

• Data collection/data management (e.g., GPRA)

• Cultural training (e.g., competence, awareness, sensitivity)

• Other (please specify): __________________________

24. For which of the following evidence-based screening/assessments have your staff received training as part of your involvement in [Grantee’s SYT-ED/SYT-I Program]? (Please check all that apply.)

• Comprehensive Adolescent Severity Inventory (CASI)

• Teen Addiction Severity Index (T-ASI)

• Global Appraisal of Individual Needs (GAIN-I)

• GAIN Lite

• GAIN SS

• GAIN Q3

• Other (please specify): _________________________

25. For which of the following evidence-based treatment approaches have your staff received training as part of your involvement in [Grantee’s SYT-ED/SYT-I Program]? (Please check all that apply.)

• Family Support Network (FSN)

• The Seven Challenges

• Multidimensional Family Therapy (MDFT)

• Adolescent Community Reinforcement Approach (A-CRA)

• Brief Strategic Family Therapy

• Family Behavior Therapy

• Parenting with Love and Limits (PLL)

• Multisystemic Therapy (MST) for Juvenile Offenders

• Chestnut Health Systems – Bloomington Adolescent Outpatient (OP)

• Intensive Outpatient Treatment Model

• Other (please specify): _______________________

26. For which trauma-informed services have staff received training as part of your involvement in [Grantee’s SYT-ED/SYT-I Program]?

27. Does anyone in your organization or outside of your organization (e.g., staff from [Grantee’s Agency]) monitor fidelity to evidence-based assessment or treatment practices?

• Yes

• No

• Don’t know

27a. If yes, please briefly describe the monitoring process and whether you have used this process to adapt the EBPs to your setting and target population.

28. Have you modified the evidence-based practices that you use in your [SYT-ED/SYT-I] program in any way?

• Yes

• No

• Don’t know

28a. If yes, please describe in what ways you have modified the evidence-based practices that you are using.

29. For each of the following statements, indicate whether you strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree.

	Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree	Don’t Know	Not Applicable
Staff were willing to adopt new evidence-based screenings/assessments						
Staff received adequate training in evidence-based screenings/assessments						
Staff were willing to adopt new evidence-based treatments						
Staff received adequate training in evidence-based treatments						
Staff were willing to adopt new trauma-informed services							
Staff received adequate training in trauma-informed services							

30. Does your organization have any outstanding workforce training needs?

• Yes

• No

• Don’t know

30a. If yes, please specify the need(s) and for each how these needs could be addressed (e.g., “Need additional individualized technical assistance training”).

31. Did your organization change its administrative policies to accommodate participation in the [SYT-ED/SYT-I] program?

• Yes

• No

• Don’t know

31a. If yes, what type of administrative policies has your organization changed?

• Electronic reporting

• Screening policies

• Billing procedures

• Contracting procedures

• Data collection for quality assurance

• Other (please specify): __________________________

32. To what extent are/were the following factors barriers to delivering the [SYT-ED/SYT-I] program in your organization?

Please read each statement and choose the response that best describes your situation.

	To a very little extent		To some extent		To a very great extent
Staff turnover	1	2	3	4	5
Competing priorities at this organization	1	2	3	4	5
Lack of available treatment or recovery support service slots for referrals	1	2	3	4	5
Staff’s lack of time	1	2	3	4	5
Inadequate training and TA resources	1	2	3	4	5
Inadequate resources for client outreach and marketing	1	2	3	4	5
Lack of participation, enthusiasm, and/or commitment from organization’s leaders	1	2	3	4	5
Other (please specify): ______________________________	1	2	3	4	5

33. To what extent do/did the following factors support the delivery of the [SYT-ED/SYT-I] program in your organization?

Please read each statement and choose the statement that best describes your situation.

	To a very little extent		To some extent		To a very great extent
Involving treatment/recovery support services staff in the initial decision to participate in the program	1	2	3	4	5
A champion within your organization	1	2	3	4	5
Making organizational changes within the organization to facilitate [SYT-ED/SYT-I] activities	1	2	3	4	5
Having training and technical assistance available from [SYT-ED/SYT-I Grantee] or another external organization	1	2	3	4	5
Participation, enthusiasm, and/or commitment from organization’s leaders	1	2	3	4	5
Other (please specify): ______________________________	1	2	3	4	5

SECTION D: SOURCES OF FUNDING AND OUTSIDE PARTNERSHIPS

In this section we are gathering information about sources of funding you may use to provide services, and information about your outside partnerships. As a reminder, unless specified differently, the information you provide should reflect the period from <<insert date>> to <<insert date>>.

34. [INITIAL SURVEY ADMINISTRATION ONLY: Prior to your involvement in the [SYT-ED/SYT-I] program, did your organization receive any federal, state or tribal funding?

• Yes

• No

• Don’t know

34a. If yes, please indicate which of the following sources previously provided funding, and describe the services/activities that these funds supported. (Please check all that apply.)

		Past funding source	Describe services/activities funded by these sources
Substance Abuse Prevention and Treatment Block Grant		
Community Mental Health Services Block Grant		
Medicaid		
Other (please specify):		
		
		

35. Does your organization currently receive federal, state, or tribal funding beyond funds received through the [SYT-ED/SYT-I] program?

• Yes

• No

• Don’t know

35a. If yes, please indicate which of the following sources currently provide funding, and describe the services/activities that these funds support. (Please check all that apply.)

		Current funding source	Describe services/activities funded by these sources
Substance Abuse Prevention and Treatment Block Grant		
Community Mental Health Services Block Grant		
Medicaid		
Other (please specify):		
		
		

36. Does your organization receive financial support from any private sources (e.g., foundations)?

• Yes

• No

• Don’t know

36a. If yes, please specify what private sources provide financial support.

37. How often does your organization collaborate with each of the following types of organizations to meet the needs of your client population?

		Never	Rarely	Occasionally	Frequently	Don’t know
Other substance abuse treatment providers						
State substance abuse authority						
Mental health treatment providers						
State mental health authority						
Primary care providers						
Education, employment, or job training providers						
Criminal justice agencies						
State Medicaid offices						
Family advocacy groups						
Policymakers/legislators						
Researchers/evaluators						
Social services providers						
Other (please specify):						
						
						
						

SECTION E: RESOURCES USED and COSTS

38. What were the total costs (labor and nonlabor) that your organization incurred during the past fiscal year in implementing the [Grantee’s SYT-ED/SYT-I Program] to provide substance abuse treatment for youth with substance abuse and/or co-occurring disorders? Do not include the value of in-kind resources (e.g., volunteer labor or donated supplies) as these will be captured below.

Total costs in past fiscal year?	$

Personnel Costs

39. What was the total labor expense (including all fringe benefits and payroll taxes) during the past fiscal year for paid employees implementing the [Grantee’s SYT-ED/SYT-I Program] within your organization to provide substance abuse treatment for youth with substance abuse and/or co-occurring disorders? These costs should include direct labor costs for clinical staff, management staff, and other support staff. Do not include the value of in-kind labor (e.g., volunteer labor) as it will be captured below.

Total costs for paid employees in past fiscal year?	$

40. For all staff in your organization who are involved in the [Grantee’s SYT-ED/SYT-I Program], please record the job types/titles you currently employ. For each job type, please also indicate the total number of full-time equivalent (FTE) persons that you employ and the number of FTE persons of that type that you hired specifically for [Grantee’s SYT-ED/SYT-I Program]. Please also indicate the typical licensures/certifications held by staff members for each job type. For the FTEs, you may enter numbers up to two decimal places.

Helpful Hint: The question above refers to staff in terms of FTEs. FTE is the fraction of time that a staff member works relative to a full-time worker (i.e., 40 hours per week). Full-time equivalent calculations should be based on a 40 hour work week. In the example shown below, if you employ two counselors and both typically work 30 hours per week, then the number of full-time equivalent counselors you employ would be given by [(30 + 30) / 40 =] 1.5. If you hired one of these counselors because of your involvement with [Grantee’s SYT-ED/SYT-I Program], then the number of FTE persons newly hired would be (30/40 =) 0.75.

Job Type/Title	FTEs	Number of newly hired FTEs	Licensure(s)/certification(s)
EXAMPLE: Counselors	1.5	0.75	National Certified Addiction Counselor, Level 1 (NCAC I) National Certified Adolescent Addiction Counselor (NCAAC) National Peer Recovery Support Specialist (NCPRSS)

Consultants or Contracted Personnel

41. 

    FOR

    EXAMPLE

    Suppose you have a contract with a registered nurse (RN), and you pay $25,000 per year for this RN to come in two days a week (or approximately 16 hours a week) to deliver medical treatment for clients enrolled in your youth program. The first line of the table below shows how you would record this information.

    For the fiscal year, list all consultants or contracted personnel that provide services for your [Grantee’s SYT-ED/SYT-I Program]; the total number of hours worked during the fiscal year; an estimated hourly compensation rate; and the percent of their time devoted to each of your treatment programs.

Personnel type		# of Hours/Year	×	Estimated Hourly Rate	=	Estimated Cost
Registered Nurse		16 × 52 = 832	$	30.05	$	25,000
			$		$
			$		$
			$		$
			$		$
			$		$
			$		$
			$		$
			$		$
			$		$

Volunteer Labor

42. 

    Suppose you have a volunteer that typically comes in 20 hours per week to help with your administrative support for your youth program. If you had to hire another staff person to fulfill the tasks that this volunteer worker performs, you might have to pay an annual salary of $20,000. The first line of the table below shows how you would record this information.

    FOR

    EXAMPLE

    For the fiscal year, list all volunteer workers involved with your organization’s [Grantee’s SYT-ED/SYT-I Program]; the total number of hours worked for your organization’s [Grantee’s SYT-ED/SYT-I Program] the during the fiscal year; and an estimated hourly compensation if you had to pay for their labor services.

Job Type		# of Hours/Year	×	Estimated Hourly Rate	=	Estimated Cost
Administrative Assistant		20 × 52 = 1,040	$	19.23	$	20,000
			$		$
			$		$
			$		$
			$		$
			$		$
			$		$
			$		$
			$		$
			$		$

Building and Facilities

43. What were the total expenses for the building space used to implement your organization’s [Grantee’s SYT-ED/SYT-I Program] during the fiscal year? If you do not know the expenses for your building space, please provide an estimate of the square footage below in Question 45.

		Total Expense
Total expense (e.g., mortgage or rent payment)	$

44. Does the expense reported in Question 11 represent the current market value of the space?

___	Yes  (Go to Question 46)
___	No (e.g., space is fully owned, provided “free,” or at a subsidized rate)  (Go to Question 45)
___	Don’t Know  (Go to Question 45)

45. How large was the total building space used by your organization to implement the [Grantee’s SYT-ED/SYT-I Program] during the fiscal year?

		Total Square Footage
Square feet of total useable space

Contracted Services

46. What was the total cost of any contracted services (e.g., laboratory services, repairs and maintenance, housekeeping, etc.) used by your organization to implement your [Grantee’s SYT-ED/SYT-I Program] during the fiscal year?

    Total costs for contracted services in past fiscal year?	$

    
    

    
    

    
    

    
    

    

    FOR

    EXAMPLEE

47. 

    Suppose you have contracts with a housekeeping company and a company that provides laboratory services for your facilities in implementing the [Grantee’s SYT-ED/SYT-I Program]. If you paid $1,200 for your housekeeping services and $5,000 for your laboratory services, then you would report $6,200 ($1,200 + $5,000) in the space provided for Question 46. In the space provided for Question 47, you would list housekeeping and laboratory services as the components comprising the figure reported in Question 46.

    Please list the types of contracted services that are included in the total costs reported in Question 46.

	Description of service
Contracted service 1
Contracted service 2
Contracted service 3
Contracted service 4
Contracted service 5

Supplies, Materials, and Minor Equipment

48. Please list the total cost for supplies, materials, and minor equipment (e.g., medications, medical supplies, office supplies, housekeeping items, linens, food, postage, computers) used by your organization to implement your [Grantee’s SYT-ED/SYT-I Program] during the fiscal year.

    Total costs for contracted services in past fiscal year?	$

    
    

    
    

    
    

    
    

    

    FOR

    EXAMPLE

49. 

    Suppose you purchase office supplies for your facility to support implementation of your [Grantee’s SYT-ED/SYT-I Program]. If you paid $2,000 for these office supplies, then you would report $2,000 in the space provided for Question 48. In the space provided for Question 49, you would list office supplies as the component comprising the figure reported in Question 48.

    Please list the types of supplies, materials, and minor equipment that are included in the total cost reported in Question 48.

	Description of supply, material, or minor equipment
Supply, material, or equipment 1
Supply, material, or equipment 2
Supply, material, or equipment 3
Supply, material, or equipment 4
Supply, material, or equipment 5

50. During the fiscal year, did you receive any supplies, materials, or minor equipment free of charge or in-kind?

___	Yes
___	No  (Go to Question 52)

51. Please list the supplies, materials, or minor equipment that you received free of charge or in-kind.

	Description of supply, material, or minor equipment
Supply, material, or equipment 1
Supply, material, or equipment 2
Supply, material, or equipment 3
Supply, material, or equipment 4
Supply, material, or equipment 5

Miscellaneous Resources

52. What was the total cost of all miscellaneous items (e.g., utilities, garbage, insurance, etc.) that were used by your organization to implement your [Grantee’s SYT-ED/SYT-I Program] during the fiscal year?

    Total costs for miscellaneous resources in past fiscal year?	$

    
    

    
    

    
    

    
    

53. Please list the types of miscellaneous items that are included in the total cost reported in Question 52.

	Description of item
Miscellaneous item 1
Miscellaneous item 2
Miscellaneous item 3
Miscellaneous item 4
Miscellaneous item 5

54. During the fiscal year, did you receive any miscellaneous items free of charge or in-kind?

___	Yes
___	No  (Go to Question 56)

55. Please list the miscellaneous items that you received free of charge or in-kind.

	Description of item
Miscellaneous item 1
Miscellaneous item 2
Miscellaneous item 3
Miscellaneous item 4
Miscellaneous item 5

Administrative Overhead

56. For the fiscal year, was there a standing overhead rate or administrative charge that was incurred by your organization in implementing its [Grantee’s SYT-ED/SYT-I Program] during the previous fiscal year?

___	Yes
___	No  Go to Question 61

57. Have you included this overhead rate or administrative charge in the cost information you have already provided in this questionnaire?

___	Yes  Go to Question 61
___	No

58. What was the overhead rate OR administrative charge?

Overhead Rate:

%

OR

Administrative Charge:

$

59. To which component is this overhead rate or administrative charge applied (check all that apply)?

___	Labor Costs
___	Total Costs
___	Other (please specify):

60. If possible, please indicate the resources this overhead money provided to your family-centered treatment programs serving pregnant or postpartum women, their minor children, and other family members (e.g., billing, payrolls, marketing, legal services, other administrative tasks):

	Description of resource
Overhead resource 1
Overhead resource 2
Overhead resource 3
Overhead resource 4
Overhead resource 5

SECTION E: WRAP UP

61. Overall, how satisfied is your organization with the [Grantee’s SYT-ED/SYT-I Program]?

• Very satisfied

• Satisfied

• Unsure

• Dissatisfied

• Very dissatisfied

• No experience

62. If you have any suggestions or comments you would like to share regarding the [Grantee’s SYT-ED/SYT-I Program], please write them below.

Thank you for completing this survey!