Form Local Provider Local Provider Local Provider

Disaster Behavioral Health Needs Assessment Survey – Local Provider Version

OMB No. xxxx-xxxx

Expiration Date: xx/xx/20xx

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Welcome to the Disaster Behavioral Health Needs Assessment Survey.

What is the goal of this survey? The Substance Abuse and Mental Health Services Administration (SAMHSA) Disaster Technical Assistance Center (DTAC) is gathering information on the needs of states, territories, federally-recognized tribes, and local organizations and agencies as they integrate disaster behavioral health (DBH) into all-hazards disaster planning and response. The goal of this survey is to learn about the current needs of local DBH providers.

Why have I been selected for this survey? You work for a local provider and your current position involves DBH preparedness or response.

Your Participation. Participation is completely voluntary. You can choose whether or not to take the survey; you can skip any questions or stop without finishing the survey. Whether or not you complete the survey will not affect any services you receive from SAMHSA DTAC.

The Survey. The survey asks you to rate the difficulty and need for training and technical assistance on several job-related activities. It also asks you to indicate how useful certain solutions and methods of training would be for your program. An Institutional Review Board (IRB) and the Office of Management and Budget (OMB) have approved all survey content. The survey will take 20–30 minutes to complete.

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 and the expiration date is xx/xx/20xx.  Public reporting burden for this collection of information is estimated to average .25 hours per client 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, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

Click to Next Page for more information.

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Who will view the survey results? If you choose to participate in the survey, any information you provide will be kept confidential to the extent provided by law and all information collected will be reported only at an aggregate level. SAMHSA/FEMA personnel, cleared by the project manager, and assigned to improving DBH services, will view Local Provider results. Participants can request their own Local Provider survey results. SAMHSA DTAC will not provide Local Provider survey results to non-participants, including Local Provider employees. SAMHSA DTAC will aggregate your survey results at the national or regional level when distributing reports outside of cleared SAMHSA/FEMA personnel.

How will survey results be used? Data will be used to identify DBH activities that are difficult and are in need of training, useful solutions for addressing challenges and barriers, and preferred methods of training and technical assistance. SAMHSA DTAC will then compare the identified activities, solutions and methods to the current training and technical assistance they offer as a basis for making improvements to better meet user needs. For example, SAMHSA DTAC will compare the preferred methods of training and technical assistance indicated by participants to current methods and determine areas where preferred methods can be incorporated.

Click one of the three options below. If you click on “Start Survey Now” or “Start Survey Later” you are giving SAMHSA DTAC permission to analyze and report on your responses to support making changes and improvements to the training and technical assistance the SAMHSA DTAC provides in order to better meet user needs.

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Start survey now

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Start survey later

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Exit survey/I do not want to participate

Important Contact Information
Questions about SAMHSA?	Contact SAMHSA Federal Project Officers: Dr. Nikki D. Bellamy, 240-276-2418, nikki.bellamy@samhsa.hhs.gov Erik Hierholzer, 240-276-0408, erik.hierholzer@samhsa.hhs.gov
Questions about the survey?	Contact SAMHSA DTAC Survey Helpdesk, DTACSurvey@icfi.com, 1-866-657-2798
Questions about SAMHSA DTAC?	Call 800-308-3515, or e-mail dtac@samhsa.hhs.gov
Questions about your rights as a participant?	Contact Dr. Janet Griffith, 703-225-2243

1. Which of the following best describes your role as a local provider related to disaster behavioral health preparation and response? (select only one)

	My role involves only disaster mental health preparation/response.
	My role involves only disaster substance abuse preparation/response.
	My role involves both disaster mental health and disaster substance abuse preparation/response.

2. Which of the following best describes your familiarity with the training and technical assistance offered by SAMHSA DTAC?

Not At All Familiar

Slightly Familiar

Familiar

Very Familiar

Extremely Familiar

Disaster Behavioral Health Preparedness Activities

For each of 12 DBH preparedness activities listed below, please rate the Importance of each activity to performing your job effectively and your Need for Support from SAMHSA DTAC.

[If hover cursor over Need for Support: “Examples of support include onsite and web-based consultation and training; grant-specific technical assistance and support for the Federal Emergency Management Agency’s Crisis Counseling Assistance and Training Program (CCP);  fact sheets, publications, studies, and articles; disaster preparation and response toolkits; assistance with establishing partnerships and collaboration with other DBH preparedness and response stakeholders; webinars and podcasts; and online discussion boards.”]

	Importance						Need for Support
	Not at all important	Slightly important	Important	Very important	Extremely important	Does not apply	No need	Slight need	Moderate need	Strong need	Extremely strong need	Does not apply
1. Working with state/territory emergency management to include local providers in disaster planning
2. Working with state/territory to tailor DBH plans to address cultural nuances (e.g., rural/urban differences)
3. Developing and coordinating DBH exercises/drills at the local level
4. Working with state/ territory DBH personnel to plan for first responder substance misuse and mental health reactions
5. Knowing exactly what to do after a disaster strikes
6. Developing an understanding of the Crisis Intervention Stress Model (CISM)
7. Developing an understanding of the Crisis Counseling Assistance and Training Program (CCP)
8. Writing FEMA grant applications
9. Providing crisis counseling
10. Practicing with a high degree of cultural sensitivity
11. Developing an understanding of the concepts of psychological first aid (PFA)
12. Soliciting contract approvals from state/territory

13. Overall, what level of training and technical assistance would be most useful in supporting your organization/agency’s DBH preparedness efforts?

Beginner

Intermediate

Advanced

14. Please list some types of support (i.e., training and technical assistance) related to DBH preparedness that would be useful to your organization/agency.

Disaster Behavioral Health Response Activities

For each of 13 DBH response activities listed below, please rate the Importance of each activity to performing your job effectively and your Need for Support from SAMHSA DTAC.

[If hover cursor over Need for Support: “Examples of support include onsite and web-based consultation and training; grant-specific technical assistance and support for the Federal Emergency Management Agency’s Crisis Counseling Assistance and Training Program (CCP);  fact sheets, publications, studies, and articles; disaster preparation and response toolkits; assistance with establishing partnerships and collaboration with other DBH preparedness and response stakeholders; webinars and podcasts; and online discussion boards.”]

	Importance						Need for Support
	Not at all important	Slightly important	Important	Very important	Extremely important	Does not apply	No need	Slight need	Moderate need	Strong need	Extremely strong need	Does not apply
1. Obtaining affordable DBH certification
2. Staffing response teams with volunteer crisis counselors
3. Obtaining participation from partners who will not be reimbursed for indirect costs by the Crisis Counseling Assistance and Training Program
4. Responding to a disaster immediately after it strikes
5. Understanding unique aspects of and challenges associated with crisis counseling
6. Sharing and updating local information with the state/territory
7. Maintaining initial disaster response until federal/state/territory funds are received
8. Working with FEMA to develop immediate service grants
9. Adapting state/territory response plans to local needs
10. Obtaining agreement from shelters to allocate space (e.g., beds) for mental health patients
11. Obtaining agreement from shelters to allocate space (e.g., beds) for people with substance misuse issues.
12. Providing continuity of care to mental health patients
13. Providing continuity of care to people with substance misuse

14. Overall, what level of training and technical assistance would be most useful in supporting your organization/agency’s DBH response efforts?

Beginner

Intermediate

Advanced

15. Please list some types of support (i.e., training and technical assistance) related to DBH response that would be useful to your organization/agency.

DBH Collaboration

Please provide a rating on the Importance of and Need for Support in collaborating with each of the 8 entities listed below.

[If hover cursor over Need for Support: “Examples of support include onsite and web-based consultation and training; grant-specific technical assistance and support for the Federal Emergency Management Agency’s Crisis Counseling Assistance and Training Program (CCP);  fact sheets, publications, studies, and articles; disaster preparation and response toolkits; assistance with establishing partnerships and collaboration with other DBH preparedness and response stakeholders; webinars and podcasts; and online discussion boards.”]

	Importance						Need for Support
	Not at all important	Slightly important	Important	Very important	Extremely important	Does not apply	No need	Slight need	Moderate need	Strong need	Extremely strong need	Does not apply
1. Emergency management staff
2. Department of Homeland Security (DHS) staff (e.g., FEMA)
3. Federal government staff other than DHS
4. Public health entities (e.g., hospitals, doctors, nurses)
5. Disaster relief groups (e.g., Red Cross)
6. Community groups
7. State/territory government within your state/territory
8. American Indian tribal communities

9. In the past 12 months, approximately how many times did your organization/agency communicate with the state/territory DBH program on Disaster Mental Health activities? (your best guess is fine)

0

1

2-5

6-9

10+

10. In the past 12 months, approximately how many times did your organization/agency communicate with the state/territory DBH program on Disaster Substance Abuse activities? (your best guess is fine)

0

1

2-5

6-9

10+

11. How can SAMHSA DTAC support collaboration between your organization/agency and state/territory DBH programs?

Methods of Training and Technical Assistance

1. Please select the three methods of training and technical assistance that you prefer most.

Methods
Conference
Distance Learning/Web
Onsite Consultation
Peer-to-Peer Learning
Phone Consultation
Fact Sheet
Toolkit
Articles (technical, academic, or popular literature)
Curricula
Seminar Workshop
Webinar (i.e., live online presentation with audience)
Podcast (i.e., recorded presentation)
Mobile applications (i.e., apps for mobile phone or tablet)

2. We understand that meeting in person when participating in training and technical assistance activities is often preferred; however, due to cost considerations, it is often not feasible. Please describe some of your preferences for non-in-person methods of training and technical assistance. Please include additional detail, such as specific topics best suited for particular non-in-person methods, if possible.

Demographics

Indicate your response by marking the box next to the response option that applies to you.

Which of the following best describes your title?		Executive
		Director
		Manager
		Other

How many years of experience do you have in the DBH field?		Less than 3 years
		3 to 5 years
		6 to 10 years
		More than 10 years

Which of the following best describes how long you have held your current position?		Less than 1 year
		1 to 4 years
		5 to 8 years
		More than 8 years

In which state/territory is your organization/agency located?
	Alabama		Idaho		Nebraska		Rhode Island
	Alaska		Illinois		Nevada		South Carolina
	American Samoa		Indiana		New Hampshire		South Dakota
	Arizona		Iowa		New Jersey		Tennessee
	Arkansas		Kansas		New Mexico		Texas
	California		Kentucky		New York		Utah
	Colorado		Louisiana		North Carolina		Vermont
	Connecticut		Maine		North Dakota		Virginia
	Delaware		Maryland		Northern Mariana Islands		U.S. Virgin Islands
	District of Columbia		Massachusetts		Ohio		Washington
	Federated States of Micronesia		Michigan		Oklahoma		West Virginia
	Florida		Minnesota		Oregon		Wisconsin
	Georgia		Mississippi		Palau		Wyoming
	Guam		Missouri		Pennsylvania
	Hawaii		Montana		Puerto Rico

Estimate the percentage of time your organization/agency’s staff has spent on DBH preparedness in the past 12 months. Your best guess is fine. Please round to the nearest percentage.

___%

Estimate the percentage of time your organization/agency’s staff has spent on DBH response in the past 12 months. Your best guess is fine. Please round to the nearest percentage.

___%

Indicate the number of staff members (including you) who are involved in DBH preparedness.

___ staff members

Indicate the number of staff members (including you) who are involved in DBH response.

___ staff members

Additional Comments

1. Please use the space below to share any additional comments with SAMHSA DTAC.

Exit Page

To submit your survey responses, click on the SUBMIT button below. Your responses will be submitted, and you will be taken to the SAMHSA DTAC website. Your responses will not be submitted if you do not click on the SUBMIT button.

[SUBMIT button]

Thank you for your participation!

SAMHSA DTAC

July 2013 18