Attachment 7 Contact Information Form

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
How satisfied are you with the overall quality of this technical assistance?	1	2	3	4	5
How satisfied are you with the quality of the staff leading the session?	1	2	3	4	5
How satisfied are you with the quality of the technical assistance materials?	1	2	3	4	5
4. Overall, how satisfied are you with your technical assistance experience?	1	2	3	4	5
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.	1	2	3	4	5
6. The material presented in this session will be useful to me in dealing with substance abuse.	1	2	3	4	5
7. The staff was knowledgeable about the subject matter.	1	2	3	4	5
8. The staff was well prepared for the course.	1	2	3	4	5
9. The staff was receptive to participants Comments and questions.	1	2	3	4	5
10. I am currently effective when working in this topic area.	1	2	3	4	5
11. The technical assistance enhanced my skills in this topic area.	1	2	3	4	5
12. The technical assistance was relevant to my career.	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.
	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
I expect to use the information gained from this technical assistance.	1	2	3	4	5
14. I expect this technical assistance to benefit my clients.	1	2	3	4	5
15. This technical assistance was relevant to substance abuse treatment.	1	2	3	4	5
16. I would recommend this technical assistance to a colleague.	1	2	3	4	5
	Very Useful	Useful	Neutral	Useless	Not Applicable
17. How useful was the information you received from the instructor?	1	2	3	4	5
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
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 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.

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