CLIENT SURVEY OF THE DELIVERY OF EVIDENCE BASED PSYCHOTHERAPY
Thank you for completing the Survey of the Delivery of Evidence Based Psychotherapy. Please read the following statement and choose "yes" or "no" below.
CONSENT TO PARTICIPATE IN THE SURVEY OF THE DELIVERY OF EVIDENCE BASED PSYCHOTHERAPY
I understand that:
I have been invited to take part in a survey that gathers information on the types of methods my therapist recently used to treat my PTSD.
The purpose of the study is to determine if the survey is a valid measure of quality of therapy for adults with PTSD.
My participation in this survey is voluntary, and I will not be penalized if I refuse to participate or decide to stop.
There is no cost to me to participate in the survey.
To the extent permitted by law, my survey responses will be kept private and secure.
My information will only be used for this survey, and my name will not be associated with my answers.
My individual answers will not be released to my therapist, the facility where I received treatment, or any other organization.
Mathematica will summarize responses from all participants and share that information with ASPE, NIMH, or other organizations to make the survey better and to improve the quality of care for patients with PTSD.
In appreciation for completing the survey, I will receive a $20 gift card from Mathematica.
I may change my mind and take back my permission at any time.
I can contact Melissa Azur, the project director, at firstname.lastname@example.org or (202) 250-3518, or Kirsten Beronio, the Contract Officer Representative at ASPE, at Kirsten.Beronio@hhs.gov to get an answer about any questions I may have.
If I have questions about my rights as a research volunteer, or feel that I have been harmed in any way by participating in the study, I can call the New England Institutional Review Board, at 1-800-232-9570.
Please initial a response:
_______ Yes, I consent to participate in the Survey of the Delivery of Evidence Based Psychotherapy.
Thank you, please continue to the next page to begin the survey.
_______ No, I do not consent to participate in the Survey of the Delivery of Evidence Based Psychotherapy.
Thank you for your response. If you have questions about the Survey of the Delivery of Evidence Based Psychotherapy or decide you would like to participate, please contact Melissa Azur, the project director, at email@example.com or (202) 250-3518.
This survey is designed to understand and improve the quality of care provided to people with PTSD. Your thoughts on your current treatment are very important to us.
Please complete this survey based on the most recent session you had with your therapist. Not all of the below items will occur in every therapy session.
Choose "yes" only if the item occurred in the most recent therapy session.
Choose "no" if the item did not occur in the most recent therapy session.
If you cannot remember if an item did or did not occur, please choose "Don't Remember".
You may skip any question you do not feel comfortable answering.
Your responses will be kept confidential and will not be shared with your therapist or anyone outside the Mathematica research team.
|During this session:||Please select one response|
|1.||Did you and your therapist discuss an agenda or plan for your session?|
|2.||Did your therapist talk about or check-in on your expectations of how therapy will go?|
|3.||Did your therapist work with you to set goals you both agreed on?|
|4.||Did your therapist help you become aware of or realize feelings, views or thoughts in your life that have been influenced by your traumatic experience?
|5.||Did your therapist ask you several direct questions to make you think critically about or examine your thoughts, feelings, or beliefs?
For example, your therapist might ask:
|6.||Did your therapist offer other ways of thinking about your issues (e.g., problem areas or areas you want to work on) related to the trauma?
|7.||Did you and your therapist discuss people, events, or places you now avoid or stay away from because of your traumatic experience?
For example, someone in a car accident might avoid driving on the freeway.
|8.||Did your therapist do any of the following things to help you deal with fear, anxiety or things you now avoid because of your trauma?|
|a) Ask you to imagine or retell your traumatic experience for longer than 10 minutes|
|b) Ask you to write about your traumatic experience|
|c) Ask you questions to make you think critically about or examine your thoughts, feelings, or beliefs related to your fear, anxiety, and avoidance of things (i.e., "How do you know this? Can you give me an example?")|
|d) Ask you to do real world experiments like visiting a place related to the traumatic experience for longer than 10 minutes|
|9.||After you described your traumatic experience, did you and your therapist discuss the details of what happened to you, how it impacted your life, or your emotions about the event?|
|10.||Did your therapist make good use of your session time today?|
|11.||Did your therapist ask for your opinion on how your treatment is going?|
|12.||Did your therapist ask for feedback on how she/he is doing in helping you recover from your PTSD?|
|13.||Did your therapist assign homework or practice assignments (to be completed by the next session) to work on your PTSD symptoms or problem areas?|
|14.||Did your therapist make sure you understood how to complete your homework for the next session?|
|15.||If you had problems completing your previously assigned homework, did your therapist work with you to come up with solutions to these problems?|
|16.||Did your therapist review and discuss your homework from the previous session?|
|17.||When reviewing the homework from the previous session, did your therapist encourage or provide you with constructive feedback?|
|During this session:||Please select one response|
|21.||a. Has your therapist ever asked you if have had thoughts about committing suicide?|
|b. During this session, did your therapist ask you if you had thoughts about committing suicide?|
|22.||a. Has your therapist ever asked you to answer questions about your PTSD symptoms? This might include completing a form before or after therapy.|
|b. During this session, did your therapist ask you about your PTSD symptoms? This might include completing a form or survey before or after therapy.|
|23.||a. Has your therapist ever provided information about PTSD and PTSD symptoms?|
|b. During this session, did your therapist provide information about PTSD and PTSD symptoms?|
|24.||a. Has your therapist ever provided with specific education on the nature of the traumatic event (i.e., facts about the type of trauma)?
|b. During this session, did your therapist ever provide you with specific education on the nature of the traumatic event (i.e., facts about the type of trauma)?
|25.||a. Has your therapist ever explained how your particular treatment will work?|
|b. During this session, did your therapist explain how your particular treatment will work?|
In appreciation for completing this survey, we would like to mail you a $20 gift card. If you would like to receive a gift card, please provide your mailing information below. We will only use this information to send you the gift card. You should receive your gift card in 2-3 weeks.
In late fall, we will be conducting telephone focus groups as a part of this study. The focus group will be about an hour long and participants will be paid a $20 gift card after participating.
May we contact you about this?
Yes Please provide best telephone number to reach you, if not provided above:
Thank you for completing this survey!
PLEASE MAIL TO MATHEMATICA POLICY RESEARCH IN THE PRE-PAID ENVELOPE PROVIDED.
|According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0418 . The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.|
OMB NO. 0990-0418
Exp. Date 05/31/2017
Approved by NEIRB on 4/29/2014
NEIRB Version No. 1.0