OMB NO. 0930-0270 

Expiration Date 08/31/2025

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. Please do not put your name on this form. If you 

filled out a form like this in the past week, please do not fill in this one. We thank you very much for your time! 

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 service 

helpful? 

One-to-one interaction (with counselor/outreach worker) Yes No Yes No

Public education presentation Yes No Yes No

Group counseling/support group Yes No Yes No

Handouts/materials Yes No Yes No

Internet sites (Crisis Counseling Assistance and Training Program [CCP] website, 

Facebook, etc.) 

Yes No Yes No

Other (please specify): Yes No Yes No

Referral resources Yes No Yes No

PLEASE ALSO ANSWER QUESTIONS ON THE BACK.

How good of a job did the counselor or outreach worker do... Extremely 

poor

Poor Fair Good Excellent 

Treating you with respect? 

1 2 3 4 5 

Respecting your culture, race, ethnicity, or religion? 

1 2 3 4 5 

Making you feel that asking for help is okay? 

1 2 3 4 5 

Making you feel that you can help yourself and your family? 

1 2 3 4 5 

Keeping things you said private? 

1 2 3 4 5 

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

Substance use Community services (e.g., Federal Emergency Management Agency, loans, housing, 

employment, social services) 

Mental health Resources for those with disabilities or other access or functional needs 

CCP services Other referral type 

(Please specify type):

In general... Extremely 

poor

Poor Fair Good Excellent 

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

disasters? 

1 2 3 4 5 

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 

Not at all 

useful 

Slightly 

useful 

Moderately 

useful 

Very 

useful 

Extremely 

useful 

How useful was this program in helping return things in 

your life back to the way they were before the disaster? 

1 2 3 4 5 

Overall, how useful was this program to you? 

1 2 3 4 5 

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.

My family member is missing or dead. 

My friend is missing or dead. 

My pet is missing or dead. 

My home is damaged or destroyed. 

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

I had other financial loss. 

I or a member of my household was injured or 

physically harmed. 

My life or that of someone in my household was 

threatened. 

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

I or a member of my household assisted with 

rescue/recovery. 

I am or a member of my household is unemployed 

because of this disaster. 

I was evacuated quickly with no time to prepare. 

I had prolonged separation from family. 

I was displaced from my home for 1 week or longer. 

PLEASE CONTINUE ON THE SECOND PAGE.

How good of a job did this program do with... Extremely 

poor

Poor Fair Good Excellent 

Helping you to know that your feelings after the disaster were the 

same as many other people’s feelings? 

1 2 3 4 5 

Helping you to find ways to take care of yourself, like eating right and 

getting enough sleep? 

1 2 3 4 5 

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

volunteer work? 

1 2 3 4 5 

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In general... 
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...

Not at all A little 

bit Somewhat Quite 

a bit 

Very 

much 

Been bothered by bad memories, nightmares, or reminders of 

what happened? 

1 2 3 4 5 

Tried NOT to think or talk about what happened or to do things 

that remind you of what happened? 

1 2 3 4 5 

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 

Been down or depressed? 

1 2 3 4 5 

Found other stressful things harder to deal with because of what 

happened? 

1 2 3 4 5 

Had trouble taking care of your health (e.g., eating poorly, not 

getting enough rest, smoking more, drinking more)? 

1 2 3 4 5 

Had difficulty getting along or having fun with family and friends? 

1 2 3 4 5 

Needed help from a counselor to deal with your reactions to the 

disaster? 

1 2 3 4 5 

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 

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 

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? 

Having less trouble working now Have about the same amount of 

trouble working now 

Have more trouble working now 

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 

PLEASE ALSO ANSWER QUESTIONS ON THE BACK.

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Questions
The final questions will help us to describe the total group of people who completed the form.

How do you identify yourself? Male Female 

In what year were you born? 

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

0-6 years Some college 

7-11 years College graduate or more 

12 years (high school diploma or GED) 

What is your annual gross household income? 

< $10,000 $10,000 - $25,000 $25,000 - $40,000 $40,000 - $51,000 >$51,000 

In what county or parish do you currently live? 

Are you Hispanic/Latino? Yes No

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

Asian

White 

American Indian/Alaska Native

Native Hawaiian/Other Pacific Islander

What is your preferred language? 

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.) 

Transgender None of these

Black or African American

Thank you for taking the time to complete this form accurately and fully!

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.

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