Form State/Territory DB State/Territory DB State/Territory DBHNAS

OMB No. 0930-xxxx

Expiration Date: xx/xx/xxxx

Attachment A.1 – State/Territory Coordinator Disaster Behavioral Health Needs Assessment

SAMHSA DTAC Disaster Behavioral Health Needs Assessment Survey

State/Territory Version

Paper Draft of Web Survey

Landing Page #1

Welcome to the Disaster Behavioral Health Needs Assessment Survey.

What is the goal of this survey? 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 State and Territory Coordinators.

Why have I been selected for this survey? You are a State/Territory coordinator and your current position involves DBH preparedness and 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 30-45 minutes to complete. If you choose to participate, we would like to receive your completed survey by [__/__/____].

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 0930-xxxx.  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.

Landing Page #2

Who will view your State/Territory’s 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 State/Territory level results. Participants can request their own State/Territory level survey results. SAMHSA DTAC will not provide State/Territory level survey results to non-participants, including State/Territory 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/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 improvement to the training and technical assistance the SAMHSA DTAC provides in order to better meet user needs.



Start survey now



Start survey later



Exit survey/I do not want to participate

[Selecting “Start survey now” will take the participant to the first item of the survey]

[Selecting “Start survey later” will take them to a page telling the participant to use the original email to return]

[Selecting “Exit survey” will take the participant to a “Thank you” page.]

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, 1-800-xxx-xxxx
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.

Definitions

Review the following terms and definitions before beginning the survey.

Program—a collection of work, activities, tasks, staff, and funding focused on disaster mental health preparedness and/or response, disaster substance abuse preparedness and/or response, or both (i.e. you are part of your State/Territory’s program)

Local Provider—a mental health or substance abuse organization that your program supports and provides resources to during a disaster

State/Territory—the State/Territory government in the State/Territory where your DBH work takes place. For purposes of this survey, State/Territory includes Washington, D.C.

Coordinator—a State/Territory employee who manages the State/Territory DBH program—either mental health, substance abuse, or both

Disaster Behavioral Health (DBH)—a behavioral health practice aimed at addressing incident-specific mental health or substance abuse reactions; DBH encompasses both disaster mental health and disaster substance abuse practices

Activities—actions you take while performing your job that directly involve mental health and/or substance abuse disaster preparedness and response

Program Staff—employees who, as part of their work, focus on a component of DBH preparedness and response and collaborate with other DBH personnel to discuss these topics

Training—any instruction, from web-based to classroom, that develops knowledge, skills, and abilities in program staff

Technical Assistance—any resource, from text to deployed personnel, that provides guidance, organization, or administration to a program

Job Role

Please review the job role definitions below, and then mark the box that best represents your job role.

Disaster Substance Abuse Coordinator—a State/Territory designee who oversees the coordination of disaster substance abuse response and recovery efforts and programs during and after any period of a disaster. This individual typically is responsible for disaster substance abuse preparedness and usually has other responsibilities at the State/Territory level. Disaster Mental Health Coordinator—a State/Territory designee who oversees the coordination of disaster mental health response and recovery efforts and programs during and after any period of a disaster. This individual typically is responsible for disaster mental health preparedness and usually has other responsibilities at the State/Territory level. Disaster Behavioral Health Coordinator—a State/Territory designee who oversees the coordination of both disaster mental health and substance abuse (together known as behavioral health) response and recovery programs during and after any period of disaster, as well as how they integrate with one another. This individual typically is responsible for disaster behavioral health preparedness and usually has other responsibilities at the State/Territory level.
Which of the following best describes your role in the disaster behavioral health (DBH) field?		Disaster Substance Abuse Coordinator
		Disaster Mental Health Coordinator
		Disaster Behavioral Health Coordinator (both Mental Health and Substance Abuse)
		Other (jobs that involve DBH) [SPECIFY]:

Section 1: DBH Preparedness First, please review the DBH Preparedness Activities listed below. Preparedness activities are DBH activities that occur before a disaster. In the section marked Difficulty, mark the box below the response option that indicates how difficult each activity is for DBH program staff. In the section marked Need, mark the box below the response option that best represents the DBH program staff's need for training and/or technical assistance on each activity.
	(a) Difficulty. Please indicate how difficult each of the following DBH preparedness activities is for DBH program staff.								(b) Need. Please indicate the DBH program staff’s need for training and technical assistance on the following DBH preparedness activities.
DBH Preparedness Activities	Not at all difficult	Slightly difficult		Moderately difficult		Very difficult	Extremely difficult	Does not apply	No need	Slight need	Moderate need	Strong need	Extremely strong need	Does not apply
	1	2		3		4	5	N/A	1	2	3	4	5	N/A
1.1(a/b). Collaborating with outside entities
Developing the State/Territory’s All-Hazards DBH Preparedness Plan	Do not respond to this row								Do not respond to this row
1.2(a/b). Generating plan buy-in with internal stakeholders
1.3(a/b). Generating plan buy-in with external entities
1.4(a/b). Developing the preparedness plan
1.5(a/b). Conducting preparedness exercises
1.6(a/b). Revising the plan
1.7(a/b). Conducting preparedness training

Section 2: DBH Response First, please review the DBH Response Activities listed below. Response activities are DBH activities that occur during (“short term”) and after (“long term”) a disaster. In the section marked Difficulty, mark the box below the response option that indicates how difficult each activity is for the DBH program staff. In the section marked Need, mark the box below the response option that best represents the DBH program staff's need for training and/or technical assistance on each activity.
	(a) Difficulty. Please indicate how difficult each of the following DBH response activities is for DBH program staff.						(b) Need. Please indicate the DBH program staff’s need for training and technical assistance on the following DBH response activities.
DBH Response Activities	Not at all difficult	Slightly difficult	Moderately difficult	Very difficult	Extremely difficult	Does not apply	No need	Slight need		Moderate need	Strong need	Extremely strong need	Does not apply
	1	2	3	4	5	N/A	1	2		3	4	5	N/A
Short Term (Acute/Immediate)	Do not respond to this row						Do not respond to this row
2.1(a/b). Implementing the State/Territory’s All-Hazards DBH preparedness plan
2.2(a/b). Coordinating DBH response
2.3(a/b). Administering DBH needs assessment
2.4(a/b). Gathering needs assessment information from facilities, clients, and other sources
2.5(a/b). Analyzing needs assessment results
2.6(a/b). Determining required level of assistance
2.7(a/b). Determining the need for DBH grants (e.g., Crisis Counseling Assistance and Training Program [CCP], SAMHSA Emergency Response Grant [SERG])
2.8(a/b). Supporting providers in meeting the needs of pre-disaster clients and affected facilities (e.g., opioid treatment providers)
Long Term (Response/Recovery)	Do not respond to this row						Do not respond to this row
2.9(a/b). Managing transition from short-term to long-term response
2.10(a/b). Providing public psychoeducation
2.11(a/b). Maintaining communication and support with providers
2.12(a/b). Managing DBH grants (if implemented)
2.13(a/b). Navigating the funding mechanism
2.14(a/b). Implementing the grant program plan of services
2.15(a/b). Participating in grant program oversight
2.16(a/b). Implementing phasedown period / final grant program reporting
2.17(a/b). Conducting mitigation (lessons learned)

Section 3: DBH Preparedness Challenges First, please review the DBH Preparedness Activities listed below. Preparedness activities are DBH activities that occur before a disaster. In the section marked Difficulty, mark the box below the response option that indicates how difficult each activity is for the DBH program staff.
Activities	Difficulty
	Not at all difficult	Slightly difficult	Moderately difficult	Very difficult	Extremely difficult	Does not apply
	1	2	3	4	5	N/A
Identifying resources for planning and preparedness activities
Improving collaboration between preparedness partners
Increasing the understanding of preparedness and planning best practices (e.g., use of National Incident Management System [NIMS] and Incident Command System [ICS])
Identifying a standardized credentialing process for volunteers/crisis responders
Generating State/Territory support for DBH planning
Generating State/Territory support for DBH exercises
Getting community mental health, substance abuse, or behavioral health centers to participate in DBH preparedness
Allocating funding for updating State-/Territory-wide DBH plans
Ensuring that volunteers and partners are up to date on required trainings
Getting local governments to incorporate DBH preparedness into county plans

First, please review the DBH Preparedness Solutions listed below. Solutions can help your staff with its DBH activities. In the section marked Need, mark the box below the response option that best represents the DBH program staff's need for training and/or technical assistance on each solution.
Solutions	Need
	No need	Slight need	Moderate need	Strong need	Extremely strong need	Does not apply
	1	2	3	4	5	N/A
Methods of achieving NIMS and ICS compliance in all-hazards plans
Approaches to funding State-/Territory-level training for community partners
Information on programs that build community resilience
Information on programs that build individual resilience
Methods of generating buy-in from other agencies while developing a disaster plan
Support in identifying free, web-provided guidance
Methods of blogging or chatting with other State/Territory coordinators
Guidance in working with local governments on information technology–based risk management (e.g., record back-up)

First, please review the training and technical assistance Methods listed below. Methods are ways that solutions can be delivered. In the section marked Usefulness, mark the box below the response option that best represents how useful each of the following methods is when receiving training and/or technical assistance on DBH Preparedness.
Methods	Usefulness
	Not at all useful	Slightly useful	Moderately useful	Very useful	Extremely useful	Does not apply
	1	2	3	4	5	N/A
Conference
Distance Learning/Web
Onsite Consultation
Peer-to-Peer Learning
Phone Consultation
Fact Sheet
Toolkit
Article
Curricula
Seminar Workshop
Training of Trainers

Section 4: DBH Response Challenges First, please review the DBH Response Activities listed below. Response activities are DBH activities that occur after a disaster. In the section marked Difficulty, mark the box below the response option that indicates how difficult each activity is for the DBH program staff.
Activities	Difficulty
	Not at all difficult	Slightly difficult	Moderately difficult	Very difficult	Extremely difficult	Does not apply
	1	2	3	4	5	N/A
Finding shelters that will accept survivors with mental health / substance abuse needs
Maintaining the fidelity of DBH models when employing response paraprofessionals
Establishing a leadership presence in an unfamiliar disaster area
Identifying resource gaps in an unfamiliar disaster area
Determining the capacity of a mental health, substance abuse, or behavioral health center during a disaster
Identifying relevant needs assessment questions
Identifying providers who have the knowledge to answer needs assessment questions
Determining how the type of disaster should affect the response
Recruiting and retaining a sufficient staff to address response activities
Coordinating the substance abuse and mental health needs assessment

First, please review the DBH Response Solutions listed below. Solutions can help your staff with its DBH activities. In the section marked Need, mark the box below the response option that best represents the DBH program staff's need for training and/or technical assistance on each solution.
Solutions	Need
	No need	Slight need	Moderate need	Strong need	Extremely strong need	Does not apply
	1	2	3	4	5	N/A
Approaches to crisis counselor certification
Support for interstate information sharing
Information on culturally appropriate outreach
Information on response for children affected during disasters
Guidance in educating staff about the grant process
Information on how to support small residential group homes during a disaster
Guidance on interfacing different fiscal management software programs used by local governments
Guidance in operating with limited resources after a disaster

First, please review the training and technical assistance Methods listed below. Methods are ways that solutions can be delivered. In the section marked Usefulness, mark the box below the response option that best represents how useful each of the following methods is when receiving training and/or technical assistance on DBH Response Solutions.
Methods	Usefulness
	Not at all useful	Slightly useful	Moderately useful	Very useful	Extremely useful	Does not apply
	1	2	3	4	5	N/A
Conference
Distance Learning/Web
Onsite Consultation
Peer-to-Peer Learning
Phone Consultation
Fact Sheet
Toolkit
Article
Curricula
Seminar Workshop
Training of Trainers

Section 5: Mental Health Preparedness Challenges [IF Q0=MENTAL HEALTH, BEHAVIORAL HEALTH, OR OTHER, COMPLETE SECTIONS 5 AND 6. IF Q0=SUBSTANCE ABUSE, SKIP TO SECTION 7]. First, please review the Mental Health Preparedness Activities listed below. Preparedness activities are DBH activities that occur before a disaster. In the section marked Difficulty, mark the box below the response option that indicates how difficult each activity is for the DBH program staff.
Activities	Difficulty
	Not at all difficult	Slightly difficult	Moderately difficult	Very difficult	Extremely difficult	Does not apply
	1	2	3	4	5	N/A
Increasing disaster behavioral health awareness among mental health professionals
Increasing mental health awareness among disaster behavioral health professionals
Indentifying instructional material on disaster mental health preparedness
Getting emergency management offices to include mental health in disaster preparedness planning
Getting agreement from organizations to shelter mental health patients during disasters

First, please review the Mental Health Preparedness Solutions listed below. Solutions can help your staff with its DBH activities. In the section marked Need, mark the box below the response option that best represents the DBH program staff's need for training and/or technical assistance on each solution.
Solutions	Need
	No need	Slight need	Moderate need	Strong need	Extremely strong need	Does not apply
	1	2	3	4	5	N/A
Guidance on collaboration when DBH is split between two departments
Guidance on presenting the importance of mental health preparedness to emergency management
Guidance on collaborating with public health entities
Support in providing free disaster mental health training to staff
Support for increasing policy requirements for disaster mental health preparedness
Guidance in developing standard operating procedures for disaster mental health preparedness

First, please review the training and/or technical assistance Methods listed below. Methods are ways that solutions can be delivered. In the section marked Usefulness, mark the box below the response option that best represents how useful each of the following methods is when receiving training and/or technical assistance on Mental Health Preparedness.
Methods	Usefulness
	Not at all useful	Slightly useful	Moderately useful	Very useful	Extremely useful	Does not apply
	1	2	3	4	5	N/A
Conference
Distance Learning/Web
Onsite Consultation
Peer-to-Peer Learning
Phone Consultation
Fact Sheet
Toolkit
Article
Curricula
Seminar Workshop
Training of Trainers

Section 6: Mental Health Response Challenges First, please review the Mental Health Response Activities listed below. Response activities are DBH activities that occur after a disaster. In the section marked Difficulty, mark the box below the response option that indicates how difficult each activity is for the DBH program staff.
Activities	Difficulty
	Not at all difficult	Slightly difficult	Moderately difficult	Very difficult	Extremely difficult	Does not apply
	1	2	3	4	5	N/A
Conducting a mental health needs assessment when Federal Emergency Management Agency [FEMA] Preliminary Damage Assessment numbers have been delayed
Developing the CCP / SERG application while responding to a disaster
Soliciting support from providers who have to pay the indirect costs that are not funded by the CCP
Working with DBH response teams to increase the involvement of mental health professionals in the response effort
Identifying relevant mental health needs assessment questions
Getting agreement from small, independently operated mental health centers to remain open during disasters
Getting shelter operators to plan for mental health issues before they open their shelters
Informing the public of the differences between mental health response and other DBH response

First, please review the Mental Health Response Solutions listed below. Solutions can help your staff with its DBH activities. In the section marked Need, mark the box below the response option that best represents the DBH program staff's need for training and/or technical assistance on each solution.
Solutions	Need
	No need	Slight need	Moderate need	Strong need	Extremely strong need	Does not apply
	1	2	3	4	5	N/A
Information on web-based data evaluation and reporting systems
Guidance on obtaining CCP program updates for coordinators who are unable to attend training
Guidance on incorporating evidence-informed interventions (e.g., Psychological First Aid [PFA]) into response efforts
Information on PFA training for trainers
Information on Psychological Recovery as a model to follow PFA
Guidance on how to affect community and responder adaptive functioning (e.g., verbal processing)

First, please review the training and technical assistance Methods listed below. Methods are ways that solutions can be delivered. In the section marked Usefulness, mark the box below the response option that best represents how useful each of the following methods is when receiving training and/or technical assistance on Mental Health Response.
Methods	Usefulness
	Not at all useful	Slightly useful	Moderately useful	Very useful	Extremely useful	Does not apply
	1	2	3	4	5	N/A
Conference
Distance Learning/Web
Onsite Consultation
Peer-to-Peer Learning
Phone Consultation
Fact Sheet
Toolkit
Article
Curricula
Seminar Workshop
Training of Trainers

Section 7: Substance Abuse Preparedness Challenges [IF Q0=SUBSTANCE ABUSE, BEHAVIORAL HEALTH, OR OTHER, COMPLETE SECTIONS 7 AND 8. IF Q0=MENTAL HEALTH, SKIP TO SECTION 9]. First, please review the Substance Abuse Preparedness Activities listed below. Preparedness activities are DBH activities that occur before a disaster. In the section marked Difficulty, mark the box below the response option that indicates how difficult each activity is for the DBH program staff.
Activities	Difficulty
	Not at all difficult	Slightly difficult	Moderately difficult	Very difficult	Extremely difficult	Does not apply
	1	2	3	4	5	N/A
Increasing disaster behavioral health awareness among substance abuse professionals
Working with emergency management to include substance abuse in disaster preparedness planning
Getting agreement from organizations to shelter active substance abusers during disasters
Ensuring that community mental health centers include substance abuse in their disaster preparedness planning
Identifying instructional material on disaster substance abuse preparedness
Increasing substance abuse awareness among disaster behavioral health professionals
Allocating funding to reimbursing individuals for substance abuse training

First, please review the Substance Abuse Preparedness Solutions listed below. Solutions can help your staff with its DBH activities. In the section marked Need, mark the box below the response option that best represents the DBH program staff's need for training and/or technical assistance on each solution.
Solutions	Need
	No need	Slight need	Moderate need	Strong need	Extremely strong need	Does not apply
	1	2	3	4	5	N/A
Methods for establishing competency-based substance abuse training
Methods of informing the public regarding the capabilities of substance abuse responders
General DBH training for the larger substance abuse workforce
Guidance on how to unify mental health and substance abuse into one program
Methods of generating greater substance abuse participation in CCPs
Guidance on collaborating with public health professionals during disaster preparedness

First, please review the training and technical assistance Methods listed below. Methods are ways that solutions can be delivered. In the section marked Usefulness, mark the box below the response option that best represents how useful each of the following methods is when receiving training and/or technical assistance on Substance Abuse Preparedness.
Methods	Usefulness
	Not at all useful	Slightly useful	Moderately useful	Very useful	Extremely useful	Does not apply
	1	2	3	4	5	N/A
Conference
Distance Learning/Web
Onsite Consultation
Peer-to-Peer Learning
Phone Consultation
Fact Sheet
Toolkit
Article
Curricula
Seminar Workshop
Training of Trainers

Section 8: Substance Abuse Response Challenges First, please review the Substance Abuse Response Activities listed below. Response activities are DBH activities that occur after a disaster. In the section marked Difficulty, mark the box below the response option that indicates how difficult each activity is for the DBH program staff.
Activities	Difficulty
	Not at all difficult	Slightly difficult	Moderately difficult	Very difficult	Extremely difficult	Does not apply
	1	2	3	4	5	N/A
Creating a standardized approach to opioid treatment provider continuity
Getting emergency management offices to include mental health in disaster preparedness planning
Providing services at American Red Cross shelters
Identifying relevant substance abuse needs assessment questions
Informing the public on how substance abuse response differs from other disaster behavioral health response
Getting small, independently operated substance abuse centers to remain open during disasters
Getting shelter operators to plan for mental health issues before they open their shelters
Providing public guidance regarding post-disaster substance abuse issues
Funding substance abuse response activities banned from the CCP program (e.g., detoxification)
Collaborating with mental health entities during CCP initiatives

First, please review the Substance Abuse Response Solutions listed below. Solutions can help your staff with its DBH activities. In the section marked Need, mark the box below the response option that best represents the DBH program staff's need for training and/or technical assistance on each solution.
Solutions	Need
	No need	Slight need	Moderate need	Strong need	Extremely strong need	Does not apply
	1	2	3	4	5	N/A
Information on Digital Access to Medication (SAMHSA pilot program for opioid treatment providers)
Information on short-term interventions (e.g., Screening Brief Intervention, Referral to Treatment model)
Guidance in integrating substance abuse response with PFA
Information on how to respond to opioid treatment issues during a disaster
Guidance on how to describe substance abuse response’s role during a disaster

First, please review the training and technical assistance Methods listed below. Methods are ways that solutions can be delivered. In the section marked Usefulness, mark the box below the response option that best represents how useful each of the following methods is when receiving training and/or technical assistance on Substance Abuse Response.
Methods	Usefulness
	Not at all useful	Slightly useful	Moderately useful	Very useful	Extremely useful	Does not apply
	1	2	3	4	5	N/A
Conference
Distance Learning/Web
Onsite Consultation
Peer-to-Peer Learning
Phone Consultation
Fact Sheet
Toolkit
Article
Curricula
Seminar Workshop
Training of Trainers

Section 9: Specific Incidents/Populations Items Awareness of Training/Technical Assistance Offered Mark the response option that indicates how aware your DBH program staff is regarding the training and technical assistance offered by SAMHSA DTAC. Mark only one response.
9.1	Not at all aware		Slightly aware		Moderately aware		Very aware		Extremely aware
	1		2		3		4		5

Training/Technical Assistance Needed on Specific Activities First, please review the Federal Fiscal Management Activities listed below. In the section marked Need, mark the box below the response option that indicates the extent of your program staff’s need for training and/or technical assistance on each activity.
Activities	Need
	No need	Slight need	Moderate need	Strong need	Extremely strong need	Does not apply
	1	2	3	4	5	N/A
Transitioning Federal funds through State/Territory mechanisms in a timely manner
Working with short deadlines as a result of establishing contracts with providers after Notice of Grant Award
Managing fiscal grant reporting
Developing budgets for grant applications
Educating State/Territory financial system employees about the nuances of the grant process
Maintaining the necessary number of staff members to coordinate required grant oversight visits

First, please review the State/Territory Fiscal Management Activities listed below. In the section marked Need, mark the box below the response option that indicates the extent of your program staff’s need for training and/or technical assistance on each activity.
Activities	Need
	No need	Slight need	Moderate need	Strong need	Extremely strong need	Does not apply
	1	2	3	4	5	N/A
Transitioning State/Territory funds through local provider mechanisms in a timely manner
Working with short deadlines as a result of establishing contracts with providers after Notice of Grant Award
Managing fiscal grant reporting
Developing budgets for grant applications
Educating local provider financial system employees about the nuances of the grant process
Maintaining the necessary number of staff members to coordinate required grant oversight visits

First, please review the Rural Planning Activities listed below. In the section marked Need, mark the box below the response option that indicates the extent of your program staff’s need for training and/or technical assistance on each activity.
Activities	Need
	No need	Slight need	Moderate need	Strong need	Extremely strong need	Does not apply
	1	2	3	4	5	N/A
Accessing rural areas prior to and during disasters
Addressing the unique DBH preparedness and response needs
Meeting the needs of the community with fewer DBH planning partners
Tailoring outreach efforts to rural culture
Partnering with FEMA officers while conducting first responder training
Addressing the stigma associated with seeking help for substance abuse and mental health issues
Tailoring training and technical assistance to meet the needs of a geographical area larger than that for which they were designed (e.g. several counties)

First, please review the Special Population Outreach Activities listed below. In the section marked Need, mark the box below the response option that indicates the extent of your program staff’s need for training and/or technical assistance on each activity.
Activities	Need
	No need	Slight need	Moderate need	Strong need	Extremely strong need	Does not apply
	1	2	3	4	5	N/A
Obtaining information from tribes that are protective of personal and tribal information
Obtaining information from schools that are protective of student access
Adapting DBH outreach materials that are too technical
Training outreach staff on the sensitivities required to serve special populations
Getting shelter managers to identify special population resources
Putting special population professionals in place at reception and destination sites
Tracking special populations and notifying destination sites of their arrival
Tailoring training to explain how to respond to special populations during disasters
Addressing language and cultural barriers

First, please review the Economic Downturn Activities listed below. In the section marked Need, mark the box below the response option that indicates the extent of your program staff’s need for training and/or technical assistance on each activity.
Activities	Need
	No need	Slight need	Moderate need	Strong need	Extremely strong need	Does not apply
	1	2	3	4	5	N/A
Supporting DBH preparedness efforts with decreased budgets
Supporting DBH response efforts with decreased budgets
Identifying the individuals who have been affected by the economic downturn
Supporting DBH efforts during a period of decreased community volunteerism
Conducting outreach using a limited budget
Identifying information on how to cope with the outcomes of the economic downturn

Section 10: Demographics

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

Which of the following best describes your employment status in terms of the DBH field?		State/Territory Employee
		Consultant/Contractor
		Other

Which of the following best describes your current employment?		Full-time
		Part-time

Which of the following best describes your years of experience 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

Indicate your response by marking the box next to the response option that applies to your DBH program. Select only one response. (Note: States/Territories marked with * will be asked the Tribal section questions).

Select the State/Territory where your DBH program is 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 State/Territory’s DBH program staff spends on preparedness. Your best guess is fine. Please round to the nearest percentage.

___%

Estimate the percentage of time your State/Territory’s DBH program staff spends on response. Your best guess is fine. Please round to the nearest percentage.

___%

Indicate the number of staff members your State/Territory’s DBH program has devoted to preparedness.

___ staff members

Indicate the number of staff members your State/Territory’s DBH program has devoted to response.

___ staff members

Section 11: American Indian Tribal Communities’ Involvement (The States/Territories that have the largest reservation populations will answer these items.)

[IF Q10.5=Alaska, Arizona, California, Montana, New Mexico, New York, North Carolina, North Dakota, Oklahoma, Oregon, South Dakota, Texas, or Washington, CONTINUE TO Q11.1. OTHERWISE, SKIP TO SECTION 12.]

Please mark the box below with the response option that indicates the extent to which your program…

	None	A little	Some	A lot	A great deal	Does not apply
	1	2	3	4	5	N/A
Collaborates with American Indian Tribal Communities in DBH preparedness planning.
Addresses American Indian Tribal Communities in the program’s DBH needs assessment survey.
Provides DBH response services to American Indian Tribal Communities.
Needs training and technical assistance in supporting the DBH needs of American Indian Tribal Communities.

5. Please use the space below to share any additional thoughts you have regarding American Indian Tribal Communities and disaster behavioral health.

[Enter response here.]

Section 12: Additional Comments

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

[Enter response here.]

Exit Page

Submit: To submit your survey responses, click on the SUBMIT link below. Your responses will be submitted, and you will be taken to the SAMHSA Disaster Technical Assistance (DTAC) website. Your responses will not be submitted if you do not click on the SUBMIT link.

[SUBMIT Link]

Thank you for your participation!

SAMHSA DTAC

31 May 2011 1