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Service Provider Feedback Form 

Today’s Date (mm/dd/yyyy)

Using a scale of 1 to 5, where 1 is extremely poor, 2 is poor, 3 is fair, 4 is good, and 5 is excellent, please rate each item below. 

These items relate to other things that can influence your work, such as supervision and support. 

Extremely 

Poor 

(1)

Poor 

(2)

Fair 

(3)

Good 

(4)

Excellent 

(5)

Quality of the supervision provided to you 

Opportunities to interact with other staff in supportive ways 

We are asking that you complete this brief form so that program administrators can learn about your opinions and experiences as 

an outreach worker, crisis counselor, team leader, or supervisor in the Crisis Counseling Assistance and Training Program (CCP). 

Do not put your name on this survey. We want you to feel completely free to express your opinion. 

Thank you for your participation!

The first set of questions is about CCP training. First, please indicate whether you have had each type of training. Then, for each 

training you have completed, please rate the usefulness of the training in preparing you to do your job, using a scale of 1 to 5, 

where 1 is not at all useful, 2 is slightly useful, 3 is moderately useful, 4 is very useful, and 5 is extremely useful. 

CCP Training Evaluation 

Have you had this 

training? 

If YES, please rate the usefulness of this training in 

preparing you to do your job. 

NO YES 

Not at 

All 

Useful 

(1)

Slightly 

Useful 

(2)

Moderately 

Useful 

(3)

Very 

Useful 

(4)

Extremely 

Useful 

(5)

Practical skills to engage survivors (e.g. 

hands-on activities, role-play) 

Explaining the “normal” or expected 

reactions to disasters 

NO YES 

Understanding the CCP outreach to 

survivors 

NO YES 

Promoting resilience 

NO YES 

Psychoeducational activities 

NO YES 

Resource linkage and identification of 

local resources for referral purposes 

NO YES 

Training on how to use the CCP Mobile 

App for data collection 

NO YES 

Training on how to complete the CCP 

data collection tools (e.g., encounter 

logs, Weekly Tally Sheet) 

NO YES 

Other crisis counseling trainings offered 

by the state or your agency (e.g., selfcare, Skills for Psychological Recovery)

NO YES 

Project # 

OMB NO. 0930-0270 

Expiration Date 08/31/2025

Items to Rate

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Extremely 

Poor 

(1)

Poor 

(2)

Fair 

(3)

Good 

(4)

Excellent 

(5)

Support and training provided to help you avoid compassion fatigue 

or to cope with the stress of listening to and helping others 

Opportunities for professional and personal growth 

Appropriateness of the workload (i.e., neither too much nor too 

little) 

Adequacy of the resources and tools you had available to do your job 

How well you understood how your job fit into the bigger picture of 

your community’s response to the disaster

How well data from the evaluation were shared with crisis 

counseling teams or used to inform their work 

How well you believe the types of services provided by the project 

matched the types of need present in the community 

The overall quality of services provided by the project 

How likely you would be to recommend this project to a friend or 

family member if he or she had the need 

Mobile Technology and Data Entry: 

Using a scale of 1 to 5, where 1 is extremely poor, 2 is poor, 3 is fair, 4 is good, and 5 is excellent, please rate each item below. 

These items relate to other things that can influence your work, such as supervision and support. 

Extremely 

Poor 

(1)

Poor 

(2)

Fair 

(3)

Good 

(4)

Excellent 

(5)

The CCP Mobile App is easily used to complete forms during and/or 

after encounters. 

The CCP Mobile App functioned as intended for collecting data. 

My team leader(s) and program management provided adequate 

support and training on the CCP Mobile App 

The data from the evaluation was shared with crisis counseling 

teams and/or was used to inform my work efficiently 

If you DID NOT use the mobile form, what prevented you from using it? (Select all that apply.) 

Not applicable; I used the 

mobile form 

Not comfortable with 

technology 

No access to mobile device Privacy concerns 

Did not understand how to use Other; please specify: 

Statements

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Were you able to understand the instructions for filling out the forms? 

Yes 

No; please specify issue: 

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 a quite a bit, and 

5 is very much, in the past month to what extent . . . 

Not at All A Little 

Bit

Somewhat Quite a 

Bit

Very 

Much 

Have you had difficulty handling other stressful events or situations 

due to your crisis counseling work or your reactions to it? 

(1) (2) (3) (4) (5)

Has the crisis counseling work or your reaction to it interfered with 

how well you take care of your physical health (e.g., eating poorly, 

not getting enough rest, smoking more, drinking more)? 

Has the crisis counseling work or your reaction to it interfered with 

your ability to work or carry out your other daily activities, such as 

housework or schoolwork? 

Has your crisis counseling work or your reaction to it affected your 

relationships with your family or friends or interfered with your 

social, recreational, or community activities? 

Have you been distressed or bothered about your reactions? 

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 xxx-xxx-xxxx.

These final questions will help us to describe the total group of people who completed this survey. 

How many hours of crisis counseling program work do you do in a typical week? 

Less than 20 hours 20–29 hours 30–39 hours 40 or more hours 

How many months have you worked with the crisis counseling program? 

(If less than 1 month, please enter 0.) 

Do you supervise the work of other crisis counselors? No Yes 

In what county or parish do you commonly work? 

Female How do you identify yourself? 

In what year were you born? 

Male Transgender None of these

Questions to React to

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What is the highest level of education you have completed or degree you have received? 

No high school High school, but no diploma or GED GED or other high school 

equivalency 

High school diploma Some college, but no degree Associate’s degree 

(e.g., A.A., A.S.) 

Bachelor’s degree Graduate or professional degree (e.g., 

M.A., Ph.D., M.D., J.D.)

Are you Hispanic/Latino? No Yes 

Which of the following best describes your race? (Please select all that apply.) 

American Indian/Alaska Native Asian 

Native Hawaiian/Other Pacific Islander

Have you been impacted by the current disaster? No Yes

If yes please answer the following questions, if no please skip to the last question (open ended) 

What is your household gross annual income? < $10,000 $10,000 to $<25,000 >$25,000 to $<40,000 

 $40,000 to $<65,000 $65,000 and more 

Before the disaster did you: 

Live alone, spouse or partner, other family (e.g., 

children/parents), roommate? No Yes 

Have employment? No Yes 

Do you own a working car? No Yes 

As a result of the disaster did you: 

Evacuated quickly with no time to prepare No Yes 

Home damage No Yes 

Vehicle or major property loss No Yes 

Disaster unemployed (self or household member) No Yes 

Have a change in cohabitation (i.e., live alone, with 

spouse/partner, other family, roommate)? No Yes 

Known someone close to you who was severely injured 

during the disaster No Yes 

Witnessed death/injury (self or household member) No Yes 

Know someone who was severely injured as a result of 

the disaster? No Yes 

Become displaced from your primary residence? 

1 to 2 months 2 to 3 months 

> 3 months

Black or African American 

White

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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.

Do you have any comments you would like to share? If so, please use the box below.