Justification

Attachment 1: SAMHSA Customer Feedback Survey

OMB No. 0930-0197

Expiration Date: 01/31/17

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 0930-0197.  Public reporting burden for this collection of information is estimated to average 5 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.

Item	Question	Notes
1	Please select the category that includes your age.	17 years and under [Exit survey if selected] 18 – 24 years 25 – 34 years 35 – 44 years 45 – 54 years 55 – 64 years 65 – 74 years 75 years and over Prefer not to respond
2	Is your primary interest in behavioral health topics?	Professional Personal
3	Are you….	Female Male Prefer not to respond
4	How do you describe your ethnicity?	Hispanic Non-Hispanic Prefer not to respond
5	How do you describe your race?	[Select all that apply] African American or Black Alaska Native American Indian Asian or Asian American Pacific Islander White or Caucasian Prefer not to respond
6	What state do you live in?	[List of U.S. States] Prefer not to respond
7	Are you living in a:	Rural area Urban area Don’t know Prefer not to respond
8	Which of the following best describes the highest level of education you have completed?	Current high school student Did not complete high school High school graduate Some college/vocational school College graduate Some postgraduate school Graduate/professional degree [Dropdown (multi-select)]: Master’s degree: M.A. M.B.A. M.Ed. M.H.S. M.P.H. M.S. M.S.W. Other master’s degree; please specify: _____ Doctorate degree: D.C. D.D.S. D.M.D. D.O.; please specify specialty:____ D.P.M. Ed.D. J.D. M.D.; please specify specialty:____ N.D. or N.M.D. Ph.D.; please specify specialty:____ Pharm.D. Psy.D. Sc.D. Other doctoral degree; please specify: _____ Other professional degree: A.T.C. L.Ac. N.P. O.T. P.A. P.T. R.N. Other professional degree; please specify: _____ Other; please specify: _____ Prefer not to respond
9	In what state did you earn your highest degree?	[List of U.S. States] I completed my degree outside the U.S.; please specify: _____ Prefer not to respond
10	How did you first hear about SAMHSA?	As a student at college/university Colleague Conference/workshop Email from SAMHSA Family/friend Online advertisement (e.g., Google ad, Facebook ad) Professional meeting Professional organization Search engine Social media (e.g., Facebook, Twitter, Instagram, LinkedIn, blog); please specify: _____ Other; please specify: _____ Prefer not to respond
11	How likely are you to recommend SAMHSA’s services to a friend or colleague?	Extremely likely Likely Neutral Unlikely Not at all likely Prefer not to respond
12	What formats do you prefer for publications and materials to support your work?	[Select all that apply] Ebooks (e.g., Epub, Kindle, etc.) HTML (e.g., web browser) Portable document format (e.g., PDF) Print Mobile apps Other; please specify: _____ Prefer not to respond
13	Do you use mobile devices, such as a smartphone or tablet, to provide care to your clients/patients (e.g., at the bedside)?	Yes No I would if I had a device Prefer not to respond
14	What best describes your organization type?	Behavioral health treatment facility Community health center Criminal justice/courts For-profit organization/company Government office Health department Health insurer Human resources/employee assistance program Military/veterans group Nonprofit/community-based organization/coalition Other health care facility (e.g., primary care, hospital, private medical practice) Rehabilitation facility/program School/university Other; please specify: _____ Prefer not to respond
15	How do you generally search for information related to work?	[Select all that apply] Colleagues Conferences/workshops Professional journals and publications Professional organizations Search engines Continuing medical education providers Other; please specify: _____ Prefer not to respond
16	Based on your response to the previous question, please name the top: Organizations Websites Conferences and workshops Professional journals and publications Other.	[Open-ended – each category will have separate text boxes for providing responses.]
17	In your own words, please describe how SAMHSA could help support your work.	[Open-ended]

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