Form Participant Feedba Participant Feedba Participant Feedback Survey Form

OMB NO. 0930-0270
Expiration Date mm/dd/yyyyy

Project #

Participant Feedback Survey
Today’s Date (mm/dd/yyyy)
This anonymous form will help community leaders learn about needs in our community, and about how well the
crisis counselors/outreach workers are meeting these needs. If you filled out a form like this in the past week,
please do not fill in this one.
Please do not put your name on this form. The filling out of this form is voluntary, and you may skip questions if
you so desire. We thank you very much for your time!
How good of a job did the counselor or outreach worker do…

Treating you with respect?
Respecting your culture, race, ethnicity, or religion?
Making you feel that asking for help is okay?
Making you feel that you can help yourself and your family?
Keeping things you said private?

Good Excellent Prefer NOT
to answer

Extremely
poor

Poor

Fair

1

2

3

4

5

6

1

2

3

4

5

6

1

2

3

4

5

6

1

2

3

4

5

6

1

2

3

4

5

6

Please indicate below which program services you have used. If you have
used the service, please indicate whether or not it was helpful to you.

Have you used
this service?

Was this Prefer NOT
service helpful? to answer

Yes

No

Yes

No

6

Yes

No

Yes

No

6

Yes

No

Yes

No

6

Yes

No

Yes

No

6

Internet sites (Crisis Counseling Assistance and Training Program [CCP] website, Yes
Facebook, etc.)

No

Yes

No

6

Yes

No

Yes

No

6

Yes

No

Yes

No

6

One-to-one interaction (with counselor/outreach worker)
Public education presentation
Group counseling/support group
Handouts/materials

Other (please specify):
Referral resources

PLEASE ALSO ANSWER QUESTIONS ON THE BACK.

If you have used referral resources, which type(s) did you utilize?
•

Substance use

•

Mental health

•

CCP services

•

FEMA-funded programs

•

Community services (e.g., loans, housing, employment, social services)

•

Resources for those with disabilities or other access or functional needs

•

Other referral type (Please specify type):

How good of a job did this program do with…

Prefer NOT
Good Excellent to answer

Extremely
poor

Poor

Fair

Helping you to know that your feelings after the disaster were the
same as many other people’s feelings?

1

2

3

4

5

6

Helping you to find ways to take care of yourself, like eating right and
getting enough sleep?

1

2

3

4

5

6

Helping you stay active in things like hobbies, sports, church, or
volunteer work?

1

2

3

4

5

Extremely
poor

Poor

Fair

How good was the information you got on how people feel after
disasters?

1

2

3

4

5

6

How good of an idea is it to tell a friend who was upset by the disaster
to see this counselor or outreach worker?

1

2

3

4

5

6

In general…

In general…

6

Prefer NOT
Good Excellent to answer

Extremely Prefer NOT
useful to answer

Not at all
useful

Slightly
useful

Moderately
useful

Very
useful

1

2

3

4

5

6

1

2

3

4

5

6

How useful was this program in helping return things in
your life back to the way they were before the disaster?
Overall, how useful was this program to you?

People experience disasters in a variety of ways. Below is a list of experiences you may have had. Please select all that
apply to you. If you were not impacted by the disaster, please skip to the next section on reactions about the disaster.
•

My family member is missing or dead.

•

My life or that of someone in my household was
threatened.

•

My friend is missing or dead.

•

I or a member of my household witnessed death/injury.

•

My pet is missing or dead.

•

I or a member of my household assisted with
rescue/recovery.

•

My home is damaged or destroyed.

•

•

I had major property loss, such as car/vehicle loss.

•

I am or a member of my household is un- or
underemployed because of this disaster.
I was evacuated quickly with no time to prepare.

•

I had other financial loss.

•

•

I or a member of my household had an illness or
was injured or physically harmed.
I or a member of my household changed schools
or learning format (e.g., virtual)
I sheltered in place or sought shelter due to
immediate threat of danger

I had prolonged separation from social network/family,
physical isolation, or social distancing.

•

I was displaced from my home for 1 week or longer.
I had disaster-caused food insecurity
I had reduced or no access to reliable information/
communication
I had reduced or no access to reliable transportation

•
•

•
•
•

PLEASE CONTINUE ON THE SECOND PAGE.

For the questions below, please share your reactions (feelings, emotions, and thoughts) about the disaster,
considering your reactions in THE PAST MONTH. Using a scale of 1 to 5, where 1 is not at all, 2 is a little bit, 3 is
somewhat, 4 is quite a bit, and 5 is very much, in the past month to what extent have you…
Very Prefer NOT
much to answer

Not at all

A little
bit

Somewhat

Quite
a bit

Been bothered by bad memories, nightmares, or reminders of
what happened?

1

2

3

4

5

6

Tried NOT to think or talk about what happened or to do things
that remind you of what happened?

1

2

3

4

5

6

Been bothered by poor sleep, poor concentration, feeling jumpy
or angry, or being scared that something else bad will happen?

1

2

3

4

5

6

1

2

3

4

5

6

1

2

3

4

5

6

Had trouble taking care of your health (e.g., eating poorly, not getting 1
enough rest, smoking/drinking/taking other substances more)?

2

3

4

5

6

1

2

3

4

5

6

1

2

3

4

5

6

Questions

Been down or depressed?
Found other stressful things harder to deal with because of what
happened?

Had difficulty getting along or having fun with family and friends?
Needed help from a counselor to deal with your reactions to the
disaster?

If you would like to speak with a counselor about your reactions or if you have concerns about your answers to
these questions, please call

Comparing your emotional and mental well-being before the disaster to now, do you feel better, worse, or about
the same?
•

Feel better now

•

Feel about the same

•

Feel worse now

Prefer NOT to answer
Comparing how well you take care of your health before the disaster to now, do you take care of your health
better, worse, or about the same?
•

Take care of your health
better now

•

Take care of your health about
the same now

•

Take care of your health
worse now

Prefer NOT to answer
Comparing how well you work (including a job, schoolwork, and housework) before the disaster to now, do you
have less trouble working, more trouble working, or about the same amount?
Have more trouble working now
•
•
•
Having less trouble working now
Have about the same amount of
trouble working now
Prefer NOT to answer
Comparing how active you were in things like hobbies, sports, church, or volunteer work before the disaster to
now, are you more active, less active, or about the same?
•

More active now

•

About the same

•

Less active now

Prefer NOT to answer
PLEASE ALSO ANSWER QUESTIONS ON THE BACK.

The final questions will help us to describe the total group of people who completed the form.
Are you? (select one)

Male

What is your age? (select one)

Young adult (18–29 years)

Female
Adult (30–64 years)

Older adult (65 years or older)

What is the highest level of education you have completed or degree you have received? (select one)

•

No high school

•

Some college

•

Some high school

•

College graduate (e.g., Associates, Bachelors)

•

High school diploma or GED

•

Graduate degree (e.g., M.S.W., Ph.D.)

What is your annual gross household income? (select one)
•

•

Less than $27,000

$27,000 - $37,000

•

$37,000 - $47,000

•

More than $47,000

In what county or parish do you currently live?

What is your race and/or ethnicity? (select all that apply)
Asian

American Indian or Alaska Native
Middle Eastern or North African

Hispanic or Latino

Black or African American

Native Hawaiian or Pacific Islander

White

What is your preferred language? (select one)
•

English

•

Spanish

•

Other (Please specify):

If you have a disability, or other access or functional need, please indicate the type (select all that apply).
•

Physical (mobility, visual, hearing, etc.)

•

Intellectual/Cognitive (learning disability, developmental delay, etc.)

•

Mental Health/Substance use (psychiatric issue, substance dependence, etc.)
Thank you for taking the time to complete this form accurately and fully!
fu

Paperwork Reduction Act Statement This information is being collected to assist the Substance Abuse and Mental Health Services Administration
(SAMHSA) with program monitoring of FEMA’s Crisis Counseling Assistance and Training Program. Crisis counselors are required to complete this form
following the delivery of crisis counseling services to disaster survivors (44 CFR 206.171 [F][3]). Information collected through this form will be used at
an aggregate level to determine the reach, consistency, and quality of the Crisis Counseling Assistance and Training Program. Under the Privacy Act of
1974, any personally identifying information obtained will be kept private to the extent of the law. 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 0930-0270. Public reporting burden for this collection of information is estimated to average 15-25 minutes per form, 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 Ln, Room 15E57B, Rockville, MD 20857.