Attachment 6 Model Statement

Form Approved OMB NO. 0930-0197 Exp. Date 12/31/2007 CENTER FOR SUBSTANCE ABUSE TREATMENT Attachment 2-2: Customer Satisfaction Survey—Meeting Follow-up
Personal ID code, date of meeting, location (i.e., city, state), and topic will be pre-coded and entered in this area of the form.
Please check here ( ) if you have received this survey in error, (i.e., you did not attend the meeting listed above) and return the uncompleted survey in the enclosed postage-paid envelope. PLEASE BASE YOUR ANSWER ON HOW YOU FEEL ABOUT THE SESSION NOW.
	Very Satisfied	Satisfied	Neutral	Dissatisfied	Very Dissatisfied
1. How satisfied are you with the overall quality of the meeting?	1	2	3	4	5
2. How satisfied are you with the quality of the information/instruction?	1	2	3	4	5
3. How satisfied are you with the quality of the meeting materials?	1	2	3	4	5
4. How satisfied are you that the meeting was relevant to substance abuse treatment?	1	2	3	4	5
5. Overall, how satisfied are you with your meeting experience?	1	2	3	4	5
PLEASE INDICATE YOUR AGREEMENT WITH THESE STATEMENTS ABOUT THE MEETING.	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
6. The material presented in the meeting has been useful to me in consensus building.	1	2	3	4	5
7. The meeting enhanced my skills in this topic area.	1	2	3	4	5
8. The meeting was relevant to my career.	1	2	3	4	5
9. The meeting has enabled me to serve my clients better.	1	2	3	4	5
10. The meeting was relevant to substance abuse treatment.	1	2	3	4	5
11. I would recommend the meeting to a colleague.	1	2	3	4	5
12. I would take additional meeting from CSAT.	1	2	3	4	5
______________________________________ Public reporting burden for this collection of information is estimated to average 10 minutes per response, 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 to the 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 0930-0197.

	Very Useful	Useful	Neutral	Useless	Not Applicable
How useful was the information you received during the meeting?	1	2	3	4	5
				Yes	No
14. Did you share any of the information from the meeting with others?				1	2
15. Did you share any of the materials from the meeting with others?				1	2
16. Have you applied any of what you learned in the meeting to your work?				1	2
What about the meeting was most useful in supporting your work responsibilities?
How can we improve our meetings?

Thank you for completing our survey.

Please return your survey in the enclosed reply envelope.

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