Form Participant Feedba Participant Feedba Participant Feedback Form

OMB NO. 0930-0270
Expiration Date XX/XX/XXXX

Project #

Participant Feedback Survey
Today’s Date (mm/dd/yyyy)
This anonymous form will help community leaders learn about needs in our community, and about how well the
crisis counselors/outreach workers are meeting these needs. Please do not put your name on this form. If you
filled out a form like this in the past week, please do not fill in this one. We thank you very much for your time!

How good of a job did the counselor or outreach worker do…

Treating you with respect?
Respecting your culture, race, ethnicity, or religion?
Making you feel that asking for help is okay?
Making you feel that you can help yourself and your family?
Keeping things you said private?

Extremely
poor

Poor

Fair

Good

Excellent

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Please indicate below which program services you have used. If you have
used the service, please indicate whether or not it was helpful to you.
One-to-one interaction (with counselor/outreach worker)
Public education presentation
Group counseling/support group
Handouts/materials
Internet sites (Crisis Counseling Assistance and Training Program [CCP] website,
Facebook, etc.)
Other (please specify):
Referral resources

Have you used
this service?

Was this service
helpful?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

PLEASE ALSO ANSWER QUESTIONS ON THE BACK.

If you have used referral resources, which type(s) did you utilize?
•

Substance use

•

Community services (e.g., Federal Emergency Management Agency, loans, housing,
employment, social services)

•

Mental health

•

Resources for those with disabilities or other access or functional needs

•

CCP services

•

Other referral type
(Please specify type):

How good of a job did this program do with…

Extremely
poor

Poor

Fair

Good

Excellent

Helping you to know that your feelings after the disaster were the
same as many other people’s feelings?

1

2

3

4

5

Helping you to find ways to take care of yourself, like eating right and
getting enough sleep?

1

2

3

4

5

Helping you stay active in things like hobbies, sports, church, or
volunteer work?

1

2

3

4

5

Extremely
poor

Poor

Fair

Good

Excellent

How good was the information you got on how people feel after
disasters?

1

2

3

4

5

How good of an idea is it to tell a friend who was upset by the disaster
to see this counselor or outreach worker?

1

2

3

4

5

In general…

In general…
How useful was this program in helping return things in
your life back to the way they were before the disaster?
Overall, how useful was this program to you?

Not at all
useful

Slightly
useful

Moderately
useful

Very
useful

Extremely
useful

1

2

3

4

5

1

2

3

4

5

People experience disasters in a variety of ways. Below is a list of experiences you may have had. Please select
all that apply to you.
•

My family member is missing or dead.

•

My life or that of someone in my household was
threatened.

•

My friend is missing or dead.

•

I or a member of my household witnessed death/injury.

•

My pet is missing or dead.

•

I or a member of my household assisted with
rescue/recovery.

•

My home is damaged or destroyed.

•

I am or a member of my household is unemployed
because of this disaster.

•

I had major property loss, such as car/vehicle loss.

•

I was evacuated quickly with no time to prepare.

•

I had other financial loss.

•

I had prolonged separation from family.

•

I or a member of my household was injured or
physically harmed.

•

I was displaced from my home for 1 week or longer.

•

My friend is missing or dead.

•

I or a member of my household witnessed death/injury.

PLEASE CONTINUE ON THE SECOND PAGE.

For the questions below, please share your reactions (feelings, emotions, and thoughts) about the disaster,
considering your reactions in THE PAST MONTH. Using a scale of 1 to 5, where 1 is not at all, 2 is a little bit, 3 is
somewhat, 4 is quite a bit, and 5 is very much, in the past month to what extent have you…
Not at all

A little
bit

Somewhat

Quite
a bit

Very
much

Been bothered by bad memories, nightmares, or reminders of
what happened?

1

2

3

4

5

Tried NOT to think or talk about what happened or to do things
that remind you of what happened?

1

2

3

4

5

Been bothered by poor sleep, poor concentration, feeling jumpy
or angry, or being scared that something else bad will happen?

1

2

3

4

5

1

2

3

4

5

Found other stressful things harder to deal with because of what
happened?

1

2

3

4

5

Had trouble taking care of your health (e.g., eating poorly, not
getting enough rest, smoking more, drinking more)?

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Questions

Been down or depressed?

Had difficulty getting along or having fun with family and friends?
Needed help from a counselor to deal with your reactions to the
disaster?

If you would like to speak with a counselor about your reactions or if you have concerns about your answers to
these questions, please call

Comparing your emotional and mental well-being before the disaster to now, do you feel better, worse, or about
the same?
•

Feel better now

•

Feel about the same

•

Feel worse now

Comparing how well you take care of your health before the disaster to now, do you take care of your health
better, worse, or about the same?
•

Take care of your health
better now

•

Take care of your health about
the same now

•

Take care of your health
worse now

Comparing how well you work (including a job, schoolwork, and housework) before the disaster to now, do you
have less trouble working, more trouble working, or about the same amount?
•

Having less trouble working now

•

Have about the same amount of
trouble working now

•

Have more trouble working now

Comparing how active you were in things like hobbies, sports, church, or volunteer work before the disaster to
now, are you more active, less active, or about the same?
•

More active now

•

About the same

•

Less active now

PLEASE ALSO ANSWER QUESTIONS ON THE BACK.

The final questions will help us to describe the total group of people who completed the form.
How do you identify yourself?

Male

•

•

Female

•

Transgender

•

None of these

In what year were you born?
What is the highest level of education you have completed or degree you have received?
•

0-6 years

•

Some college

•

7-11 years

•

College graduate or more

•

12 years (high school diploma or GED)

What is your annual gross household income?
•

< $10,000

•

•

$10,000 - $25,000

$25,000 - $40,000

•

$40,000 - $51,000

•

>$51,000

In what county or parish do you currently live?
Are you Hispanic/Latino?

•

Yes

•

No

Which of the following best describes your race? (Please select all that apply.)
•

American Indian/Alaska Native

•

Asian

•

Native Hawaiian/Other Pacific Islander

•

White

•

Black or African American

What is your preferred language?
•

English

•

Spanish

•

Other (Please specify):

If you have a disability, or other access or functional need, please indicate the type (select all that apply).
•

Physical (mobility, visual, hearing, etc.)

•

Intellectual/Cognitive (learning disability, developmental delay, etc.)

•

Mental Health/Substance use (psychiatric issue, substance dependence, etc.)

Thank you for taking the time to complete this form accurately and fully!
fu
Paperwork Reduction Act Statement This information is being collected to assist the Substance Abuse and Mental Health Services Administration
(SAMHSA) with program monitoring of FEMA’s Crisis Counseling Assistance and Training Program. Crisis counselors are required to complete this form
following the delivery of crisis counseling services to disaster survivors (44 CFR 206.171 [F][3]). Information collected through this form will be used at
an aggregate level to determine the reach, consistency, and quality of the Crisis Counseling Assistance and Training 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 OMB control number. The OMB control number for this
project is 0930-0270. Public reporting burden for this collection of information is estimated to average 15-25 minutes per form, 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 15E57B, Rockville, MD 20857.