Form Mobile App Form Mobile App Form Mobile App Form

OMB No. 0930-xxxx

Expiration Date: xx/xx/xx

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 15 minutes per respondent, 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 2-1057, Rockville, Maryland, 20857.

SAMHSA <<NAME>>Mobile App Feedback Form

Thank you for using this SAMHSA <<NAME>> mobile application (app). Please take a few minutes to answer the questions below to tell us what you think about this app. Your responses will help us continue to enhance the materials we provide.

Participation is completely voluntary. You can choose whether or not to take the feedback form; you can skip any questions or stop without finishing the feedback form. Whether or not you complete the feedback form will not affect any services you receive from SAMHSA. Click one of the options below. If you click on “Start Survey Now” you are giving SAMHSA permission to analyze and report on your responses to support making changes and improvement to the SAMHSA <<NAME>> app in order to better meet user needs.

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Start Feedback Form now

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1. How did you hear about this app?

• An email from SAMHSA

• The SAMHSA website

• A colleague

• Some other way [specify]:

1. Have you had the opportunity to use this app in the field to aid disaster/trauma survivors?

   • Yes (if yes, skip logic to Q3)

   • No (if no, skip logic to Q5)

3. How useful is this app to you?

• Not at all useful

• Somewhat useful

• Useful

• Very useful

• Extremely useful

4. Overall, how satisfied are you with this app?

• Not at all satisfied

• Somewhat satisfied

• Satisfied

• Very satisfied

• Completely satisfied

5. What are one or two ways that this app could be enhanced?

6. How likely are you to recommend the X app to colleagues? Please press the number on a scale of 1 to 10, with 1 indicating very unlikely and 10 very likely:

Least Likely Most Likely

1 2 3 4 5 6 7 8 9 10

7. What are your primary job roles? (select all that apply)

• Mental health professional

• Substance abuse professional

• Emergency responder

• State/territory/tribe government disaster behavioral health, mental health, or substance abuse coordinator

• Other state government employee [specify]:

• Local government disaster behavioral health, mental health, or substance abuse employee

• Other local government employee [specify]:

• Federal government employee [specify agency and title]:

• General public

• Other [specify]:

8. Please use the space below to provide any additional feedback you have regarding this app.

Thank you for taking the time to provide us your feedback on this SAMHSA app!