Attachment A: Service Pre-Assessment Form
OMB No. 0930-0xxx
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 0930-0xxx. Public reporting burden for this collection of information is estimated to average 60 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, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.
INITIAL INVITATION
Dear <first name> <last name>,
You are invited to participate in the <name of workshop> workshop on <date of workshop>. On behalf of the Center of Excellence for the Infant and Early Childhood Mental Health Consultation (IECMHC) initiative, I would like to welcome you in advance.
To assist us in customizing the training to best address your personal needs, background and resources, we have developed a brief pre-assessment form. We are asking you to fill out this form as part of your registration. For your convenience, you can simply click on the link below to begin. If clicking on the link does not open a browser window, you can copy the link and paste it into the address bar of your browser.
Click on this link to begin the feedback survey: <link to feedback survey>
Please complete your registration and the assessment at your earliest convenience or by <closing date> at the latest. Thank you for your valuable participation.
Sincerely,
<name of workshop facilitator>
Workshop Facilitator
Training Pre-Assessment Form
This webinar offers practitioners <description of course>, using case examples to highlight <course description>.
This webinar will be held on <month, day, year>.
First Name
Last Name
Email Address
Primary Phone Number in case we need to contact you (enter as ### - ### - ####)
Agency/Organization Affiliation
What is your job title?
What is your role in the agency through which you are participating?
What is the primary focus of the agency through which you are participating?
In what state/tribe/jurisdiction do you work? (Please select the primary location of the organization/agency through which you are participating.) Please note that choices are listed alphabetically by STATE, TRIBE and then TERRITORY/JURISDICTION.
How long have you worked in the mental health consultation field?
(Mental health consultation includes capacity building for infant and early childhood staff and family members to promote social and emotional development in children and transform children’s challenging behaviors. Services may include directly observing children and the caregiving environment, and designing interventions that involve changes in the behaviors of caregivers.)
I have not worked in the mental health consultation field
Under 1 year
1-5 years
6-10 years
11-15 years
Over 15 years
Please indicate in which of the following areas you have had substantive work experience. We have left room next to each choice for you to briefly describe that experience. (Choose all that apply.)
Mental Health Services
Early Care and Education
Home Visiting
Legislative Government
PreK-12 Education
Higher Education
Medical/Health Services
Social Services
Other (Please specify)
How would you rate your
experience with each of the following mental health consultation
activities?
<List of activities tailored to training topics
and content> Examples may include the following:
Supervision of Infant and Early Childhood Mental Health Consultants
Best practices associated with integration of early childhood mental health consultation in early care settings
Capacity-building
training for mental health consultants working in Early Head Start
and Head Start programs
<Answer choices for each item: No
Experience, A Little Experience, Some Experience, A Great Deal of
Experience>
Please rate your level of knowledge and understanding about the following topic areas. (Choose all that apply.)
Evidence-based practice in infant and early childhood mental health consultation
Integration of early childhood mental health consultation in home visiting programs
Strategies for prevention of expulsions in early care and education settings
Leveraging of private and public funding streams to support state/tribe early childhood mental health consultation
The foundation and principles of cultural competency
Applying cultural competence principles to mental health consultation practice
Early childhood mental health consultation: working in tribal communities
Other Areas (Please describe the area)___________________________________________
<Answer choices for each item: Not At All Knowledgeable, Not Very Knowledgeable, Somewhat Knowledgeable, Fairly Knowledgeable, Very Knowledgeable>
We are required to collect demographic information on recipients of this service. Your responses will remain private and will only be reported in aggregate with those of other participants.
Which of the following best describes you in terms of Hispanic or Latino heritage? (Choose one.)
Hispanic/Latino
Not Hispanic/Latino
I prefer not to answer
Which of the following best describes you in terms of race/ethnicity? (Choose all that apply.)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
I prefer not to answer
REMINDER INVITATION
Dear <first name> <last name>,
We recently sent you an invitation to participate in the <name of workshop> workshop on <date of workshop>. On behalf of the Center of Excellence for the Infant and Early Childhood Mental Health Consultation (IECMHC) initiative, I would like to welcome you in advance.
To assist us in customizing the training to best address your personal needs and resources, we have developed a brief pre-assessment form. We are asking you to fill out this form as part of your registration. For your convenience, you can simply click on the link below to begin. If clicking on the link does not open a browser window, you can copy the link and paste it into the address bar of your browser.
Click on this link to begin the feedback survey: <link to feedback survey>
Please complete your registration and the assessment at your earliest convenience or by <closing date> at the latest. Thank you for your valuable participation.
Sincerely,
<name of workshop facilitator>
Workshop Facilitator
LAST REMINDER INVITATION
Dear <first name> <last name>,
We recently sent you an invitation to participate in the <name of workshop> workshop on <date of workshop>. On behalf of the Center of Excellence for the Infant and Early Childhood Mental Health Consultation (IECMHC) initiative, I would like to welcome you in advance. Please note that registration for the training will soon be closing. If you are interested in attending this training you will need to respond by <closing date>.
To assist us in customizing the training to best address your personal needs and resources, we have developed a brief pre-assessment form. We are asking you to fill out this form as part of your registration. For your convenience, you can simply click on the link below to begin. If clicking on the link does not open a browser window, you can copy the link and paste it into the address bar of your browser.
Click on this link to begin the feedback survey: <link to feedback survey>
Please complete your registration and the assessment at your earliest convenience or by <closing date> at the latest. Thank you for your valuable participation.
Sincerely,
<name of workshop facilitator>
Workshop Facilitator
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Landon, Mary Kay |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |