APPENDIX C

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Form Approved 
OMB NO. 0930-0197 
Exp. Date 12/31/2007 


CENTER FOR SUBSTANCE ABUSE TREATMENT


Attachment 2-1:  Customer Satisfaction Survey—CSAT Meeting

Please enter the Personal ID Code you used on the consent form here _____________.

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 this meeting?

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5
    2. How satisfied are you with the quality of the information/instruction from this meeting?

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5
    3. How satisfied are you with the quality of the meeting materials?

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4.	Overall, how satisfied are you with the meeting experience?
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PLEASE INDICATE YOUR AGREEMENT WITH THESE STATEMENTS ABOUT THE MEETING.

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
5.	The meeting class was well organized.
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6.	The material presented in this meeting class will be useful to 	me in dealing with substance abuse.

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7.	I expect to use the information gained from this meeting.
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8.	I expect this meeting to benefit my clients.
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9.	This meeting was relevant to substance abuse treatment.

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10.	I would recommend this meeting to a colleague.
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________________________________________
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
11.	How useful was the information you received?
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12.	Please indicate which title best describes your job:
___Medical Director		___Clinical Administrator/Manager		___Federal Government Official
___Physician			___Clinical Supervisor			___State Government Official
___Nurse			___Psychologist				___County Government Official
___Physician's Assistant		___Counselor				___Researcher
___Pharmacist			___Social Worker			___Other (please specify)____________
___Manager/Director

13.	Please indicate which best describes your agency or affiliation:
___Federal Government		___Substance Abuse Treatment Program		
___State Government		___University or other higher education institution
___County Government		___Other (please describe)_________________________________
___Local Government		

14.	What is your gender?		1.____Male	2.____Female

15.	Are you Hispanic or Latino?	1.____Yes	2.____No

    16. What is your race (Mark all that apply)?
____Black or African American	____Alaska Native
____Asian			____American Indian
____White			____Native Hawaiian or Other Pacific Islander




What about the meeting was most useful in supporting your work responsibilities?







How can we improve our meetings?







Thank you for completing our survey.
Return your survey to the Survey Administrator for your Session.