APPENDIX C

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

CENTER FOR SUBSTANCE ABUSE TREATMENT

Attachment 2-3: Customer Satisfaction Survey—Technical Assistance

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

Date of technical assistance, 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 technical assistance 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 technical assistance?

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    2. How satisfied are you with the quality of the staff leading the session?

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    3. How satisfied are you with the quality of the technical assistance materials?

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4.	Overall, how satisfied are you with your technical assistance 	experience?
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PLEASE INDICATE YOUR AGREEMENT WITH THESE STATEMENTS ABOUT THE TECHNICAL ASSISTANCE.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
5.	The technical assistance was well organized.
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6.	The material presented in this session will be useful to me in 	dealing with substance abuse.

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7.	The staff was knowledgeable about the subject matter.
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8.	The staff was well prepared for the course.
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9.	The staff was receptive to participants Comments and 	questions.

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10.	I am currently effective when working in this topic area.
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11.	The technical assistance enhanced my skills in this topic area.
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12.	The technical assistance was relevant to my career.
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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.








Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
    13.  I expect to use the information gained from this technical assistance.
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14.  I expect this technical assistance to benefit my clients.
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15.  This technical assistance was relevant to substance abuse treatment.
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16.  I would recommend this technical assistance to a colleague.
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Very Useful
Useful
Neutral
Useless
Not
Applicable






17.	How useful was the information you received from the 	instructor?
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    18. Please indicate which title best describes your job:
___Medical Director		___Clinical Administrator/Manager		___State Government Official
___Physician			___Clinical Supervisor			___County Government Official
___Nurse			___Psychologist				___Researcher
___Physician's Assistant		___Counselor				___Other (please specify)____________
___Pharmacist			___Social Worker			
___Manager Director		___Federal Government Official

    19. 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		

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

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

    22. 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 technical assistance was most useful in supporting your work responsibilities?




How can CSAT improve its technical assistance?




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