Form Service Provider F Service Provider F Service Provider Feedback Form

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

Project #

Service Provider Feedback Form
Today’s Date (mm/dd/yyyy)
We are asking that you complete this brief form so that program administrators can learn about your opinions and experiences as
an outreach worker, crisis counselor, team leader, or supervisor in the Crisis Counseling Assistance and Training Program (CCP).
Do not put your name on this survey. We want you to feel completely free to express your opinion.
Thank you for your participation!
The first set of questions is about CCP training. First, please indicate whether you have had each type of training. Then, for each
training you have completed, please rate the usefulness of the training in preparing you to do your job, using a scale of 1 to 5,
where 1 is not at all useful, 2 is slightly useful, 3 is moderately useful, 4 is very useful, and 5 is extremely useful.
Have you had this
training?
CCP Training Evaluation
NO

YES

Practical skills to engage survivors (e.g.
hands-on activities, role-play)
Explaining the “normal” or expected
reactions to disasters
Understanding the CCP outreach to
survivors

NO

NO

NO

Training on how to use the CCP Mobile
App for data collection

NO

NO

Training on how to complete the CCP
data collection tools (e.g., encounter
logs, Weekly Tally Sheet)

NO

Other crisis counseling trainings offered
by the state or your agency (e.g., selfcare, Skills for Psychological Recovery)

NO

Slightly
Useful

Moderately
Useful

Very
Useful

Extremely
Useful

(2)

(3)

(4)

(5)

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

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

YES

YES

YES

Psychoeducational activities
Resource linkage and identification of
local resources for referral purposes

Not at
All
Useful
(1)

YES

Promoting resilience
NO

If YES, please rate the usefulness of this training in
preparing you to do your job.

YES

YES

YES

YES

Using a scale of 1 to 5, where 1 is extremely poor, 2 is poor, 3 is fair, 4 is good, and 5 is excellent, please rate each item below.
These items relate to other things that can influence your work, such as supervision and support.
Items to Rate
Quality of the supervision provided to you

Extremely
Poor
(1)

Poor

Fair

Good

Excellent

(2)

(3)

(4)

(5)

1

2

3

4

5

1

2

3

4

5

Opportunities to interact with other staff in supportive ways

PLEASE CONTINUE ON THE NEXT PAGE.

Extremely
Poor
(1)

Poor

Fair

Good

Excellent

(2)

(3)

(4)

(5)

Support and training provided to help you avoid compassion fatigue
or to cope with the stress of listening to and helping others

1

2

3

4

5

Opportunities for professional and personal growth

1

2

3

4

5

Appropriateness of the workload (i.e., neither too much nor too
little)

1

2

3

4

5

Adequacy of the resources and tools you had available to do your job

1

2

3

4

5

How well you understood how your job fit into the bigger picture of
your community’s response to the disaster

1

2

3

4

5

How well data from the evaluation were shared with crisis
counseling teams or used to inform their work

1

2

3

4

5

How well you believe the types of services provided by the project
matched the types of need present in the community

1

2

3

4

5

The overall quality of services provided by the project

1

2

3

4

5

How likely you would be to recommend this project to a friend or
family member if he or she had the need

1

2

3

4

5

Mobile Technology and Data Entry:
Using a scale of 1 to 5, where 1 is extremely poor, 2 is poor, 3 is fair, 4 is good, and 5 is excellent, please rate each item below.
These items relate to other things that can influence your work, such as supervision and support.

Statements

Extremely
Poor
(1)

Poor

Fair

Good

Excellent

(2)

(3)

(4)

(5)

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

The CCP Mobile App is easily used to complete forms during and/or
after encounters.
The CCP Mobile App functioned as intended for collecting data.
My team leader(s) and program management provided adequate
support and training on the CCP Mobile App
The data from the evaluation was shared with crisis counseling
teams and/or was used to inform my work efficiently

If you DID NOT use the mobile form, what prevented you from using it? (Select all that apply.)
•

Not applicable; I used the
mobile form

•

Not comfortable with
technology

•

No access to mobile device

•

Privacy concerns

•

Did not understand how to use

•

Other; please specify:

PLEASE CONTINUE ON THE NEXT PAGE.

Were you able to understand the instructions for filling out the forms?
•

Yes

•

No; please specify issue:

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 a quite a bit, and
5 is very much, in the past month to what extent . . .
Not at All

Somewhat

(1)

A Little
Bit
(2)

1

2

3

4

5

Has the crisis counseling work or your reaction to it interfered with
how well you take care of your physical health (e.g., eating poorly,
not getting enough rest, smoking more, drinking more)?

1

2

3

4

5

Has the crisis counseling work or your reaction to it interfered with
your ability to work or carry out your other daily activities, such as
housework or schoolwork?

1

2

3

4

5

Has your crisis counseling work or your reaction to it affected your
relationships with your family or friends or interfered with your
social, recreational, or community activities?

1

2

3

4

5

Have you been distressed or bothered about your reactions?

1

2

3

4

5

Questions to React to
Have you had difficulty handling other stressful events or situations
due to your crisis counseling work or your reactions to it?

(3)

Quite a
Bit
(4)

Very
Much
(5)

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 xxx-xxx-xxxx.
These final questions will help us to describe the total group of people who completed this survey.
How many hours of crisis counseling program work do you do in a typical week?
•

•

Less than 20 hours

•

20–29 hours

•

30–39 hours

40 or more hours

How many months have you worked with the crisis counseling program?
(If less than 1 month, please enter 0.)
•

Do you supervise the work of other crisis counselors?

No

•

Yes

In what county or parish do you commonly work?
How do you identify yourself?

•

Male

•

Female

•

Transgender

In what year were you born?

PLEASE CONTINUE ON THE NEXT PAGE.

•

None of these

What is the highest level of education you have completed or degree you have received?
•

•

No high school

•

High school diploma

•

Bachelor’s degree

Are you Hispanic/Latino?

•

•

Some college, but no degree

•

Graduate or professional degree (e.g.,
M.A., Ph.D., M.D., J.D.)
•

No

GED or other high school
equivalency
Associate’s degree
(e.g., A.A., A.S.)

•

High school, but no diploma or GED

•

Yes

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

American Indian/Alaska Native

•

Asian

•

Native Hawaiian/Other Pacific Islander

•

White

•

No

Have you been impacted by the current disaster?

•

•

Black or African American

Yes

If yes please answer the following questions, if no please skip to the last question (open ended)
What is your household gross annual income? • < $10,000

•

$10,000 to $<25,000

•

•

$40,000 to $<65,000

• $65,000

>$25,000 to $<40,000
and more

Before the disaster did you:
•

Live alone, spouse or partner, other family (e.g.,
children/parents), roommate?

◦

No

◦

Yes

•

Have employment?

◦

No

◦

Yes

•

Do you own a working car?

◦

No

◦

Yes

As a result of the disaster did you:
•

Evacuated quickly with no time to prepare

◦

No

◦

Yes

•

Home damage

◦

No

◦

Yes

•

Vehicle or major property loss

◦

No

◦

Yes

•

Disaster unemployed (self or household member)

◦

No

◦

Yes

•

Have a change in cohabitation (i.e., live alone, with
spouse/partner, other family, roommate)?
Known someone close to you who was severely injured
during the disaster

◦

No

◦

Yes

◦

No

◦

Yes

•

•

Witnessed death/injury (self or household member)

◦

No

◦

Yes

•

Know someone who was severely injured as a result of
the disaster?

◦

No

◦

Yes

•

Become displaced from your primary residence?
•

< 1month

•

> 3 months

•

1 to 2 months

PLEASE CONTINUE ON THE NEXT PAGE.

•

2 to 3 months

Do you have any comments you would like to share? If so, please use the box below.

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.