Post Event Form - Post Event Form - Domestic

Protocol for New GPRA Process for all US-based TTCs

 

The Technology Transfer Center Networks comprise all Regional and National ATTCs, MHTTCs and PTTCs. A uniform data collection tool will be used by all grantees.

 

GPRA Post-Event Form - Domestic (GPRA- PEF-D):

·         This form will collect information on participant demographics and satisfaction with the TTC event.

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

 

GPRA Follow-up Form - Domestic (GPRA-FU-D): (aka the 30-day follow-up)

·         This form will collect follow-up data for events lasting at least three hours (or more) in length.

·         This form will collect information on application and usefulness of the information gained during the TTC event.

 

 

OMB No. 0930-03xx

Expiration Date: xx/xx/2020

Burden Statement: This information is being collected to assist the Substance Abuse and Mental Health Services Administration (SAMHSA) for the purpose of program monitoring of the Technology Transfer Centers (TTC) Network Program. This voluntary information collected will be used at an aggregate level to determine the reach, consistency, and quality of the TTC Program. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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 0930-03xx. Public reporting burden for this collection of information is estimated to average less than 10 minutes per encounter, 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 Ln, Room 15 E57B, Rockville, MD 20857.

TTC GPRA Post-Event Form - Domestic (GPRA-PEF-D)

Event Name: ____________________________

Please print clearly in the boxes below using blue or black ink. Print only one number or letter in each square. Upper case letters only.

1. What is your gender?

   1. Female

   2. Male

   3. Transgender

   4. None of these

2. What is your race? (Select one or more):

   1. American Indian or Alaska Native

   2. Asian

   3. Black or African American

   4. Hispanic or Latino

   5. Native Hawaiian or Other Pacific Islander

   6. White

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

   1. Less than high school

   2. High school diploma or equivalent (GED)

   3. Some college, but no degree

   4. Associate’s degree

   5. Bachelor’s degree

   6. Master’s degree

   7. Doctor of Pharmacy (PharmD)

   8. Doctor of Medicine or Doctor of Osteopathy

   9. Other Doctoral degree or Equivalent (e.g., PhD, EdD, DPT)

   10. Other, please specify:

4. What is your primary profession? (Select one):

   1. Addictions Professional

   2. Psychiatrist

   3. Psychologist

   4. Counselor

   5. Social Worker

   6. Recovery specialist

   7. Peer professional

   8. Criminal justice/law enforcement professional

   9. Community health worker

   10. Health educator

   11. Educator

   12. Public or Business Administrator

   13. Researcher

   14. Physician

   15. Physician Assistant

   16. Nurse

   17. Pharmacist

   18. Advance Practice Registered Nurse

   19. Nurse Practitioner

   20. Nurse Midwife

   21. Dentist

   22. Student

i. Full time ___

ii. Part-time (not working)___

iii. Part-time (working)

23. Other (please specify):

5. What is your principal employment setting? (Select one):

1. Substance use disorder treatment program

2. Substance use disorder prevention program

3. Community recovery support program

4. Group home

5. Transitional/supported living facility

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

7. Community health

8. Primary care

9. Solo practice

10. Group practice

11. Hospital

12. FQHC hospital

13. State psychiatric hospital

14. Skilled nursing facility

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

16. Military/VA

17. Higher education setting

18. Elementary or secondary education setting

19. Community-based organization (including faith-based organizations)

20. Community coalition

21. Other (please specify):

6. What is the zip code of your principal employment setting?

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

   1. Very Satisfied

   2. Satisfied

   3. Neutral

   4. Dissatisfied

   5. Very Dissatisfied

8. I expect this event to benefit my professional development and/or practice.

   1. Strongly Agree

   2. Agree

   3. Neutral

   4. Disagree

   5. Strongly Disagree

9. I will to use the information gained from this event to change my current practice.

   1. Strongly Agree

   2. Agree

   3. Neutral

   4. Disagree

   5. Strongly Disagree

10. I would recommend this training to a colleague.

Yes

No

Thank you for completing our survey.

Return your survey to the Survey Administrator for your Session.