DONE 50072 SUB-1 Meeting Consent Form

Part 1 - Consent Form

As the National Screening, Brief Intervention and Referral to Treatment Addiction Technology Transfer Center (NSBIRT), we are required to report to the Center for Substance Abuse Treatment (CSAT) your feedback concerning the training, technical assistance, or meeting event in which you are participating. The information you provide is very important in determining which aspects of the training are most useful. We will ask you for your feedback during this event and then one month following this event. Participation is voluntary. You may refuse to participate or discontinue participation at any time should you change your mind without loss of benefits to which you would otherwise be entitled. All responses to the customer surveys are reported in an anonymous way. We will only record an anonymous personal code that you will provide us on the customer surveys and your name or personal information will never be used in any reporting. We appreciate your participation in this survey. If you have any questions you may contact Ireta at 412-258-8565 or email info@ireta.org.

Question Title

* CONTACT INFORMATION

Name:

Question Title

* WORK ADDRESS

Agency Name:

Address:

Address 2:

City/Town:

State:

ZIP/Postal Code:

Email Address:

Phone Number:

Question Title

* Are you willing to be contacted for a brief one-month follow up of this event?

Yes

Yes? Look for our 30-day follow up survey in your email

You will now be redirected to the webinar evaluation . It is an anonymous survey and none of the contact information above will be linked.