Form TTA Post Event For TTA Post Event For TTA Post Event Form

Form Approved

OMB NO. 0930-xxxx

Exp. Date xx/xx/xxxx

Training and Technical Assistance (TTA)
GPRA Post-Event Form–(GPRA-PEF)

Public reporting burden for this collection of information is estimated to average 10 minutes to complete this questionnaire. Send comments regarding this burden estimate or any other aspect of this collection of information to the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57A, 5600 Fishers Lane, Rockville, MD 20857. 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 control number for this project is 0930-xxxx.

Protocol for New GPRA Process for all TTA Programs

The Training and Technical Assistance programs are SAMHSA programs funded with the intent to support community and professional development. A uniform data collection tool will be used by all TTA grantees.

Government Performance and Results Act (GPRA) Post-Event Form (GPRA-PEF):

• This form will collect information on participant demographics and satisfaction with the TTA event.

• The GPRA-PEF will be used for all events (presentations, training, technical assistance, and meetings) regardless of the length of the event.

TTA GPRA Post-Event Form (GPRA-PEF)

Event Name: __________________________________

Please print clearly in the boxes below using blue or black ink. Print only one number or letter in each space. Uppercase letters only. Provide the last 3 digits of your personal zipcode; last 4 digits of your phone number; 2 digit birth year; first 3 letters of preferred name.

Personal Code (please use uppercase letters): Ex. 734036172BRI

Provide unique identifying instructions (12 characters)

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

LAST 3 ZIPCODE LAST 4 DIGITS PH NO. BIRTH YR FIRST 3 PREFERRED NAME

1. What do you consider yourself to be?

Male

Female

Transgender (Male to Female)

Transgender (Female to Male)

Gender non-conforming

Other (Specify)______________________________

Prefer not to answer

2. Are you Hispanic, Latino/a, or Spanish origin?

Yes

No

Prefer not to answer

[IF YES] What ethnic group do you consider yourself? You may indicate more than one.

Central American

Cuban

Dominican

Mexican

Puerto Rican

South American

Other (Specify)_____________

Prefer not to answer

3. What is your race? You may indicate more than one.

Black or African American

White

American Indian

Alaska Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander

Other (Specify)_____________

Prefer not to answer

4. Do you think of yourself as…

Straight Or Heterosexual

Homosexual (Gay Or Lesbian)

Bisexual

Queer, Pansexual, And/Or Questioning

Asexual

Something Else? Please Specify ___________________________________

Prefer not to answer

5. Please select the best category that describes your community (Select one or more):

Metropolitan or Suburban Community (communities located in a city or town)

Tribal Community (any American Indian or Alaska Native tribe, band, nation, pueblo, village, or community)

Rural or Frontier Community (sparsely populated areas that are geographically isolated from population centers and services, usually has few homes or other buildings, and not very many people)

Unknown

Another: _______________________

6. What is the highest degree you have received? (Select one):

Less than 12th Grade

12th Grade/High School Diploma/Equivalent

Vocational/Technical (Voc/Tech) Diploma

Some College or University

Bachelor’s Degree (For example: BA, BS)

Graduate Work/Graduate Degree

Other (Specify)____________________________________

Prefer not to answer

7. What is your primary occupation/profession? (Select one):

Addictions Professional

Psychiatrist

Psychologist

Counselor/therapist (all types)

Social Worker

Recovery coach

Peer recovery specialist

Prevention specialist

Case manager/care coordinator

Clinical supervisor

Faith leader

Community Health Worker/Educator/Health Educator

Criminal Justice/Law Enforcement Professional

Public or Business Administrator

Researcher

Physician

Physician Assistant

Pharmacist

Nurse/Nurse Practitioner

Advance Practice Registered Nurse

Midwife

Faith Leader

Teacher/educator

Dentist

Student

i. Full-time _____

ii.Part-time (not working) _____

iii.Part-time (working)_____

Business owner

Rural worker or Farmer

Family member/caregiver

Retired

Another (please specify):

8. If you are a Student, what is your primary field of study? (If Not a Student SKIP this question)

Addiction Medicine

Counseling

Criminal Justice/Law Enforcement

Medicine (general or residency)

Nursing (general or registered nurse)

Nursing Practitioner

Peer or Recovery Specialist

Pharmacy

Physician Assistant

Prevention science

Psychiatry

Psychology

Public Health (Master’s or PhD)

Recovery Coach

Social Work

Certification program

Another (please specify): _____________________________________

9. Which of the following best describes your principal employment setting? (Select one):

State/county/jurisdiction/territorial/tribal government

Substance use disorder treatment program

Substance use prevention program

Community recovery support program

Group home

Transitional/supported living facility

Mental health clinic or treatment program (Community mental health program)

Community health/Community health coalition

Community coalition

Primary care

Federally Qualified Health Centers (FQHC)

Hospital

State or private psychiatric hospital

Aging Services Network

Skilled nursing facility

Criminal justice/corrections (court, prison, jail, prison/probation, TASC)

Military/VA

Higher education setting

Elementary or secondary education setting

Community-based organization (including faith-based organizations)

Self-employed (any type of business)

Farm or rural establishment

Family-run or consumer-run organization

Homecare

Shelter

Government

Other (please specify):

10. What is the ZIP Code of your principal employment setting or school (if you are a student)?

11. How satisfied were you with the overall quality of this event?

Very Satisfied

Satisfied

Neutral

Dissatisfied

Very Dissatisfied

12. I expect this event to benefit me and/or my community.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

13. If you are a practicing healthcare provider, counsellor, preventionist, social worker, educator or work in the criminal justice/law enforcement field (if not SKIP this question) I expect this event will improve my ability to work effectively.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

14. I would recommend this event to a friend/colleague.

Yes

No

Open ended questions

15. What about the event was most useful to you? ____________________________________

16. How could this event be improved? _____________________________________________

Thank you for completing our survey.

Return your survey to the Survey Administrator for your Session.