Technical.Assistan Technical.Assistance.Post.Event.Form

Form Approved

OMB NO. 0930-0216

Exp. Date 09/30/2016

See burden statement on the reverse side

Addiction Technology Transfer Center (ATTC) Network

Post-Event Form for Technical Assistance

			Participants – Please Write Your Unique Personal Code Here as Follows:
			First Letter of Mother’s First Name:						First Letter of Mother’s Maiden Name:
			First Digit of Social Security Number:						Last Digit of Social Security Number:
			Office Use Only - ATTC Event Code:
		How satisfied are you with the overall quality of this technical assistance?					Very Satisfied			Satisfied		Neutral			Dissatisfied			Very Dissatisfied
		How satisfied are you with the quality of the staff leading the session?
		How satisfied are you with the quality of the technical assistance materials?
		Overall, how satisfied are you with your technical assistance experience?
		PLEASE INDICATE YOUR AGREEMENT WITH THESE STATEMENTS ABOUT THE SESSION. The technical assistance was well organized.					Strongly Agree			Agree		Neutral			Disagree			Strongly Disagree
		The material presented in this session will be useful to me in dealing with substance abuse.
		The staff was knowledgeable about the subject matter.
		The staff was well prepared for the course.
		The staff was receptive to participant comments and questions.
		I am currently effective when working in this topic area.
		The technical assistance enhanced my skills in this topic area.
	Please Continue to Next Page
													Strongly Agree			Agree			Neutral			Disagree					Strongly Disagree
The technical assistance was relevant to my career.
I expect to use the information gained from this technical assistance.
I expect this technical assistance to benefit my clients.
This technical assistance was relevant to substance abuse treatment
I would recommend this technical assistance to a colleague.
					Very Useful			Useful			Neutral			Useless			Not Applicable
				How useful was the information you received from the instructor?

18. Your gender:  Female  Male  Transgender

19. Are you Hispanic or Latino/a?  Yes  No

20. What is your race? (select one or more):

 American Indian  Alaska Native	 Native Hawaiian  Other Pacific Islander
 Asian	 White
 Black or African American	 Other (please specify) _______________

21. What is the highest degree you have received (select one)?

 Some high school, but no diploma or equivalent

 High school diploma or equivalent

 Some college but no degree

 Associate's degree

 Bachelor's degree

 Master's degree

 Doctoral degree or equivalent

 Other (please specify): _________________

Please Continue to Next Page

22. What is your primary profession (select one)?

 Counselor  Addictions professional  Social worker  Recovery specialist  Mental health professional  Criminal justice/law enforcement professional  Disease intervention specialist/investigator

 Community health worker  Health educator  Educator (post-secondary or continuing)  Public or Business Administrator  Researcher  Physician  Physician assistant

 Registered nurse  Licensed practical nurse  Advanced practice nurse  Pharmacist  Dentist  Other dental professional  Other (please specify)_____________

23. If you are a student, what is your primary field of study (select one)?

 Not a student	 Counseling
 Psychology	 Social Work
 Medicine	 Nursing
 Pharmacology	 Dentistry
 Basic, translational or applied science	 Criminal justice/law enforcement
 Addiction	 Education
 Public health	 Public or business administration
 Other (please specify)

24. In which discipline(s) are you currently licensed or certified (select one or more)?

 Not licensed or certified	 Addictions prevention, treatment or recovery
 Counseling	 Psychology
 Social Work	 Medicine
 Nursing	 Pharmacology
 Dentistry	 Other (please specify)________________

25. Which best describes your role at your current workplace (select one)?

 Clinician / care provider/direct service provider  Clinical Supervisor  Recovery Specialist  Manager / coordinator/administrator  Client / patient educator  Case manager  Prevention case manager

 Counselor  Mental health therapist  Parole/Probation/Re-Entry Support  Outreach staff  Disease intervention/investigation  Resident / fellow  Teacher / faculty

 Trainer / TA Provider  Group Facilitator  Not currently employed  Other (please specify)_____________

Please Continue to Next Page

26. Which best describes your principal employment setting (select one)?

 Community or Faith-based service organization (CBO/FBO)  Government (federal, state or municipal)  State/local health department  School/university (academic department)  Hospital/Hospital-affiliated clinic  HMO/managed care organization  Solo/group private practice  Addictions treatment program (inpatient)  Addictions treatment program (outpatient)  Addictions treatment program (residential)  Recovery support program

 School/university-based health clinic  Correctional facility  Probation/parole office  Local law enforcement department  Military/VA  Tribal/Indian Health Service  Community health center  Not currently employed  Other: (please specify) _________________

27. What is the zipcode of your principal employment setting? 

28. What about the technical assistance was most useful in supporting your work responsibilities?

29. How can the ATTC Network improve its technical assistance?

Participants – Please Write Your Unique Personal Code Here as Follows:
First Letter of Mother’s First Name:
First Letter of Mother’s Maiden Name:
First Digit of Social Security Number:
Last Digit of Social Security Number:

Thank you for completing our survey.

Return your survey to the Survey Administrator for your Session.

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 0930-0216.  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, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20852.