Form District Collabora District Collabora District Collaborator Survey

OMB No 0930-XXXX

Expiration Date: XX/XX/XXXX

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 20 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.

Substance Abuse and Mental Health Services Administration

Multi-Site Evaluation of the Safe Schools Healthy Students State Program

District Collaborator Informed Consent and Survey

The U.S. Substance and Mental Health Services Administration is sponsoring a multi-site evaluation of the Safe Schools / Healthy Students (SS/HS) State Program in seven states. The Program funds participating states to disseminate and support planning and implementation of the SS/HS Framework for early childhood development, violence and substance abuse prevention, mental health services, and school safety in three select school districts in each state. The purpose of the multi-site evaluation is to gather and assess information on state and district implementation, collaboration and delivery of evidence-based services for children and youth.

The purpose of this survey is to learn from your experience as a participant in your district’s collaborative planning, guidance, and support of the program. The survey is part of the Multi-Site Evaluation which is designed to produce lessons that may help design and implement future SS/HS state programs, or strengthen existing programs. Existing evaluation and research has established the effectiveness of well implemented SS/HS programs. Your response to this survey will contribute to successful expansion of this proven program nationwide.

The SS/HS District Collaborator Survey asks for information about you and your agency/organization’s role in the collaboration, and your perceptions of how the collaboration functions.

Here are some things we want you to know about completing the survey:

• Completing this survey is completely voluntary.

• You may choose not to answer any question or to stop answering questions at any time, for any reason.

• Completing the survey will take approximately 20 minutes. You may stop and restart the survey. You can stop the survey by closing your internet browser. All of your responses to that point will be saved. To continue the survey, reenter your SHEDS username and password on the website to continue the survey where you left off.

• Any information that you provide will be kept strictly confidential. No one other than evaluation staff will know who you are and what answers you gave. Any reports from this survey will share results in group form. Your name will not be used in any reports produced from information collected by this survey, and no quotes will be used that will identify you individually.

• There will be no direct benefit to you from participating in this evaluation. There are no foreseeable risks associated with participation in this survey.

• A report that combines what is learned from all of the completed surveys will be sent to SAMHSA and be accessible to grantees. Grantees may share that report with others at their discretion.

• Any questions you have about the study can be answered at any time by Mary Spooner of ICF International at (404) 321-3211, or at Mary.Spooner@icfi.com.

By completing and submitting the survey, you certify that you have read the above, that you understand its content, and that you freely agree to participate in this survey. Thank you in advance for your willingness to participate.

I do not consent

I consent

While district collaborations take different forms, we will use several standard terms to designate collaboration components about which we will ask.

• Partnership includes all persons who are part of the network of agencies, organizations, and individuals who are involved in the SS/HS State Program work in a district. It is the most inclusive network of contributors at the district level.

• Project refers to the program primarily funded through the SS/HS Program from the Substance Abuse and Mental Health Services Administration.

• Members refers to individual representatives and organizations that are on the district’s Core Management Team

What is your role in the partnership? (check all that apply)

• Member of the Core Management Team

• Member of a district working or advisory committee

• SS/HS district program staff

• Collaborating district agency staff

• Representative of an LEA/district

• Representative of local collaborating public agency(ies)

• Representative of a non-governmental collaborating organization

• Youth representative

• Parent representative

• Evaluation representative

• Other consultant or contractor representative: please specify content area: _________________

• Other: please specify _______________

Which sector does your agency or organization represent?

• Education

• Juvenile Justice

• Law Enforcement

• Mental Health

• Other: Please specify: ____________________

What is the name of the agency/organization you represent?

__________________________________________________

Approximately what percentage of your work time do you spend on SS/HS matters?

• 91 to 100%

• 51 to 90 %

• 26 to 50 %

• 11 to 25 %

• 6 to 10 %

• 5 % or less

Please rate your level of agreement with the following statements:

Statement	Strongly Agree	Somewhat Agree	Neither Agree nor Disagree	Somewhat Disagree	Strongly Disagree	Insufficient familiarity/ knowledge to Respond
The partnership is a valuable asset of the project
The project does not have the needed resources (facilities, in-kind, financial, and human)
The partnership has clear communication among members
One or more partners have not been participating effectively
The partners have changed policies, laws, and/or regulations to facilitate achieving the project’s goals
The members of the partnership share a common vision of what should be accomplished
The members of the partnership share a common vision of how the vision should be implemented
Members of the partnership do not feel connected with one another (e.g., there is no feeling of synergy)
The leadership facilitates and supports teambuilding by capitalizing on diversity
The leadership facilitates and supports teambuilding by capitalizing on individual, group, and organizational strengths
Partners have limited influence on the important decisions made by the partnership
The partners understand the community, including its people, cultures, values, and norms

The partnership is not contributing significantly to your organization’s central mission and goals
The partnership is achieving its intended goals
The partners contribute resources (e.g., money, personnel, facilities)
The partners share responsibility for the project
There is a sense of excitement associated with the project
The organization is satisfied with the quality of collaboration among partners
The multiagency partnership has effective leadership
The partnership leaders are able to continually energize the members
The partnership leaders are able to mobilize members toward common goals
The partnership leaders make me feel welcome at meetings
The partnership leaders understand the values and culture of each partner agency

Our partnership builds social time for members into meetings and events
Members participate in social activities outside formal meetings
All members are treated equally and with respect
Members are asked about their interests and needs
Member contributions are recognized
Successes are celebrated
Members actively participate in the decisionmaking process
Members feel free to speak their views without being criticized
I feel strongly committed to this partnership
The organizers stay with the effort even through the hard times to help the partnership overcome obstacles
The partnership has kept the demands on members simple and realistic
The partnership does not rely too heavily on any one member
The partnership has explored ways of securing continued financial support
As a result of this partnership, services/programs to address the identified need in the community have improved
As a result of this partnership, accessibility to services and programs has improved
As a result of this partnership, policies, rules, or laws have been changed to support a new, effective way of “doing business”
As a result of this partnership, people are better off in our community

Partners play different roles in a collaborative effort, bringing unique capacity, expertise, and resources. Using the following rating scale, describe the degree of contribution you have made or the organization you represent has made over the past year:

	No Contribution / role	Minor Contribution	Moderate Contribution	Significant Contribution	Leading Contribution	Insufficient famil-iarity/ knowledge to Respond
STRATEGIC PLANNING: e.g., providing materials, writing assistance, decision input to the district comprehensive plan (preparation / revision/ application).
ACTIVITY PLANNING: e.g., Planning for specific tasks within the SS/HS district collaborative effort
PROVIDING/ LEVERAGING FUNDING RESOURCES; e.g., Participating in providing specific funding for SS/HS collaborative tasks; collaborative budget requests;
PROVIDING / LEVERAGING HUMAN RESOURCES: e.g., reallocating staff to participate in SS/HS tasks and activities; enabling local reallocation of staff to SS/HS tasks and activities
PROVIDING / LEVERAGING INFORMATION RESOURCES: e.g., providing passive informational resources (any media), participating in dissemination networks
PROVIDING / LEVERAGING TRAINING / TA RESOURCES; e.g., providing face-to-face or web-based training or TA to SS/HS related audiences; participating or providing support to SS/HS sub-grantee trainings
MONITORING / ACCOUNTABILITY; e.g., Evaluation activities, providing/ collecting monitoring or evaluation data; disseminating and making use of performance monitoring and evaluation data

Characterize your interactions with each of the partner sector representatives. Identify the number of agencies / organizations with which you interacted in each listed sector. Each specific agency should be counted for just one category.

• Rarely worked or participated in SS/HS meetings with them (Monthly or less)

• Occasionally worked or participated in SS/HS meetings with them

• Often worked with them in task-focused meetings in addition to SS/HS meetings

• Regularly worked with them by exchanging data, information, or resources to plan for a specific piece of the SS/HS project

• Regularly and extensively worked with them to plan and implement across one or more major components of the SS/HS project

	# of Agencies / Organbizations	Rarely	Occasionally	Often	Regularly	Regularly and Extensively	I Represent This Partner	Insufficient famil-iarity/ knowledge to Respond
District educational agency (ies)
School district(s)
School(s)
State justice system agency(ies)
Local law enforcement
Local court systems
State mental health agency(ies)
Local mental health agency(ies)
State substance abuse agency(ies)
Local substance abuse agency(ies)
State family / child agency(ies)
Local family / child agency(ies)
State consultants / contractors (excluding SS/HS evaluator)
Local consultants / contractors
Other (specify)

Please indicate the response that best indicates the relative emphasis that your SS/HS collaboration places on each of the following objectives:

	No emphasis/ Not Addressed	Minor Emphasis	Moderate Emphasis	Significant Emphasis	Priority Emphasis	Insufficient famil-iarity/ knowledge to Respond
The use of evidence based practices
Reducing health disparities among youth
Integrating mental health services in schools
Cultural and linguistic inclusion
Involving families in their schools
Creating a more positive school climate
Promoting restorative school discipline policies (e.g., reduced suspension / expulsion
Increasing early childhood social / emotional development services and access
Involving community members / organizations in their schools
Preventing / reducing substance use among youth
Improving use of technology to advance SS/HS objectives
Reducing violent behavior in youth
Promoting positive youth development
Creating safe schools
Strengthening the communities capacity to achieve SS/HS goals
Increasing services and opportunities for high need populations
Sustaining SS/HS principles and strategies
Other specify:

Thank you for sharing your experiences with the SS/HS District Program !

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