12. Your gender:  Female  Male  Transgender 

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

14. 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) _______________ 

15. 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): _________________ 

16. 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 specify)_____________ 

specialist/investigator  Physician assistant 

17. 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) 

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

 

18. 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)________________ 

19. 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 specify)_____________ 

 Manager /  Outreach staff 

coordinator/administrator  Disease 

 Client / patient educator intervention/investigation 

 Case manager  Resident / fellow 

 Prevention case manager  Teacher / faculty 

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

 Community or Faith-based service organization  School/university-based health clinic

(CBO/FBO)  Correctional facility 

 Government (federal, state or municipal)  Probation/parole office 

 State/local health department  Local law enforcement department 

 School/university (academic department)  Military/VA 

 Hospital/Hospital-affiliated clinic  Tribal/Indian Health Service 

 HMO/managed care organization  Community health center 

 Solo/group private practice  Not currently employed 

 Addictions treatment program (inpatient)  Other: (please specify) _________________  Addictions treatment program (outpatient) 

 Addictions treatment program (residential) 

 Recovery support program 

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

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Revised: 6/3/2010 Page 3 of 4 v2.1 
22. What about the meeting was most useful in supporting your work responsibilities? 

23. How can the ATTC Network improve its meetings? 

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