FEEDBACK FORM 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! How good of a job did the counselor or outreach worker do… (From one to five; one being extremely poor and five being excellent.) Treating you with respect? 12345 Respecting your culture, race, ethnicity, or religion? 12345 Making you feel that asking for help is okay? 12345 Making you feel that you can help yourself and your family? 12345 Keeping things you said private? 12345 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. One-to-one interaction (with counselor/outreach worker): Have you used this service? YesNo Was this service helpful? YesNo Public education presentation: Have you used this service? YesNo Was this service helpful? YesNo Group counseling/support group: Have you used this service? YesNo Was this service helpful? YesNo Handouts/materials: Have you used this service? YesNo Was this service helpful? YesNo Internet sites (Crisis Counseling Assistance and Training Program [CCP] website, Facebook, etc.): Have you used this service? YesNo Was this service helpful? YesNo Referral resources: Have you used this service? YesNo Was this service helpful? YesNo Other (please specify): Have you used this service? YesNo Was this service helpful? YesNo If you have used referral resources, which type(s) did you utilize? Substance useCommunity services (e.g., Federal Emergency Management Agency, loans, housing, employment, social services)Mental healthResources for those with disabilities or other access or functional needsCCP servicesOther referral type (Please specify type): How good of a job did this program do with… (From one to five; one being extremely poor and five being excellent.) Helping you to know that your feelings after the disaster were the same as many other people’s feelings? 12345 Helping you to find ways to take care of yourself, like eating right and getting enough sleep? 12345 Helping you stay active in things like hobbies, sports, church, or volunteer work? 12345 In general How good was the information you got on how people feel after disasters? 12345 How good of an idea is it to tell a friend who was upset by the disaster to see this counselor or outreach worker? 12345 (From one to five; one being not at all useful and five being extremely useful.) How useful was this program in helping return things in your life back to the way they were before the disaster? 12345 Overall, how useful was this program to you? 12345 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 friend is missing or dead.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.I or a member of my household witnessed death/injury. 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… Been bothered by bad memories, nightmares, or reminders of what happened? 12345 Tried NOT to think or talk about what happened or to do things that remind you of what happened? 12345 Been bothered by poor sleep, poor concentration, feeling jumpy or angry, or being scared that something else bad will happen? 12345 Been down or depressed? 12345 Found other stressful things harder to deal with because of what happened? 12345 Had trouble taking care of your health (e.g., eating poorly, not getting enough rest, smoking more, drinking more)? 12345 Had difficulty getting along or having fun with family and friends? 12345 Needed help from a counselor to deal with your reactions to the disaster? 12345 Comparing your emotional and mental well-being before the disaster to now, do you feel better, worse, or about the same? Feel better nowFeel about the sameFeel 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 nowTake care of your health about the same nowTake 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 nowHave about the same amount of trouble working nowHave 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 nowAbout the sameLess active now The final questions will help us to describe the total group of people who completed the form. How do you identify yourself? MaleFemale In what year were you born? What is the highest level of education you have completed or degree you have received? 0-6 years7-11 years12 years (high school diploma or GED)Some collegeCollege graduate or more In what county or parish do you currently live? Are you Hispanic/Latino? YesNo Which of the following best describes your race? (Please select all that apply.) Asian or Pacific IslanderBlack or African AmericanAmerican Indian or Alaska NativeWhite or CaucasianOther (Please specify): What is your preferred language? EnglishSpanishOther (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, mental retardation, etc.)Mental Health/Substance use (psychiatric issue, substance dependence, etc.)
