Strongly Agree Neutral Disagree Strongly 

Agree Disagree
 

12. The technical assistance was relevant to my 

career. 

13. I expect to use the information gained from 

this technical assistance. 

14. I expect this technical assistance to benefit my 

clients. 

15. This technical assistance was relevant to 

substance abuse treatment 

16. I would recommend this technical assistance 

to a colleague. 

Very 

Useful 

Useful Neutral Useless Not 

Applicable 

17. How useful was the information you received 

from the instructor? 

18. Your gender:  Female  Male  Transgender 

19. Are you Hispanic or Latino/a?  Yes  No 

20. What is your race? (select one or more): 

 Alaska Native  Native Hawaiian 

 American Indian  Other Pacific Islander 

 Asian  White 

 Black or African American  Other (please specify) _______________ 

21. What is the highest degree you have received (select one)? 

 Some high school, but no diploma or equivalent 

 High school diploma or equivalent 

 Some college but no degree 

 Associate's degree 

 Bachelor's degree 

 Master's degree 

 Doctoral degree or equivalent 

 Other (please specify): _________________ 

Please Continue to Next Page 

Revised: 6/3/2010 Page 2 of 4 v2.1 
 

 

 

 

 

22. What is your primary profession (select one)? 

 Counselor  Community health worker 

 Addictions professional  Health educator  Registered nurse 

 Social worker  Educator (post-secondary or  Licensed practical nurse 

 Recovery specialist continuing)  Advanced practice nurse 

 Mental health professional  Public or Business  Pharmacist 

 Criminal justice/law Administrator  Dentist 

enforcement professional  Researcher  Other dental professional 

 Disease intervention  Physician  Other (please 

specialist/investigator  Physician assistant specify)_____________ 

23. If you are a student, what is your primary field of study (select one)? 

 Not a student  Counseling 

 Psychology  Social Work 

 Medicine  Nursing 

 Pharmacology  Dentistry 

 Basic, translational or applied science  Criminal justice/law enforcement 

 Addiction  Education 

 Public health  Public or business administration 

 Other (please specify) 

24. In which discipline(s) are you currently licensed or certified (select one or more)? 

 Not licensed or certified  Addictions prevention, treatment or 

recovery 

 Counseling  Psychology 

 Social Work  Medicine 

 Nursing  Pharmacology 

 Dentistry  Other (please specify)________________ 

25. Which best describes your role at your current workplace (select one)? 

 Clinician / care  Counselor  Trainer / TA Provider 

provider/direct service provider  Mental health therapist  Group Facilitator 

 Clinical Supervisor  Parole/Probation/Re-Entry  Not currently employed 

 Recovery Specialist Support  Other (please 

 Manager /  Outreach staff specify)_____________ 

coordinator/administrator  Disease 

 Client / patient educator intervention/investigation 

 Case manager  Resident / fellow 

 Prevention case manager  Teacher / faculty 

Please Continue to Next Page 

Revised: 6/3/2010 Page 3 of 4 v2.1 
 

26. Which best describes your principal employment setting (select one)? 

 Community or Faith-based service organization 

(CBO/FBO) 

 Government (federal, state or municipal) 

 State/local health department 

 School/university (academic department) 

 Hospital/Hospital-affiliated clinic 

 HMO/managed care organization 

 Solo/group private practice 

 Addictions treatment program (inpatient) 

 Addictions treatment program (outpatient) 

 Addictions treatment program (residential) 

 Recovery support program 

 School/university-based health clinic 

 Correctional facility 

 Probation/parole office 

 Local law enforcement department 

 Military/VA 

 Tribal/Indian Health Service 

 Community health center 

 Not currently employed 

 Other: (please specify) _________________ 

27. What is the zip code of your principal employment setting? 

28. What about the technical assistance was most useful in supporting your work responsibilities? 

29. How can the ATTC Network improve its technical assistance? 

Participants – Please Write Your Unique 

Personal Code Here as Follows: 

First Letter of Mother’s First Name: 

First Letter of Mother’s Maiden Name: 

First Digit of Social Security Number: 

Last Digit of Social Security Number: 

Thank you for completing our survey. 

Return your survey to the Survey Administrator for your Session. 

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the 

time for completing this questionnaire. Send comments regarding this burden estimate or any other aspect of this 

collection of information to SAMHSA Reports Clearance Officer, Room 7-1044, 1 Choke Cherry Road, Rockville, MD 

20857. 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 control number for this project is 0930-0216. 

Revised: 6/3/2010 Page 4 of 4 v2.1