Form CMHS-Survey

OMB No. 0930-0197 Expiration Date: 1/31/2011

SAMHSA.gov

The Substance Abuse & Mental Health Services Administration

Public Burden Statement: 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 OMB control number for this project is 0930-0197.  Public reporting burden for this collection of information is estimated to average 4 minutes per client per year, 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, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

Center for Mental Health Services (CMHS)

Your Opinion is Important To Us!

Help Improve Our Service To You By Providing Valuable Feedback!

The Center for Mental Health Services (CMHS) provides national leadership in the Federal effort to promote effective mental health services in every community and an improved state of mental health within the Nation.

CMHS is committed to providing high quality services, gaining insight regarding customer satisfaction, and targeting areas in need of improvement. We take pride in our work and value your feedback to ensure we maintain an excellent level of performance. Please take a few moments to complete this survey so we can continue to serve you better. We welcome your comments.

Sincerely yours,

A. Kathryn Power, M.Ed.

Director, Center for Mental Health Services

Substance Abuse and Mental Health Services Administration

Federal Employees - Click here to start •.

All Others - Click here to start •.

SAMHSA.gov

The Substance Abuse & Mental Health Service Administration

Center for Mental Health Services (CMHS)

Customer Satisfaction Survey

1. Which CMHS service did you receive? (check all that apply)

Telephone or Email Consultation ____ Technical Assistance or Training ____ Site Visit ____

Presentation ____ Report or Publication ____ Web Link or Web Info ____ Other ____

2. Who provided you with this service? ______________________________________

3. What was the date(s) of this service? ______________________________________

4. Responsiveness

(timeliness of service) O Excellent O Good O Fair O Poor O N/A

5. Courtesy of CMHS

employee(s) providing O Excellent O Good O Fair O Poor O N/A

service

6. Quality of Service O Excellent O Good O Fair O Poor O N/A

7. Efficiency of Service O Excellent O Good O Fair O Poor O N/A

8. Follow Through/Follow Up O Excellent O Good O Fair O Poor O N/A

9. Overall Satisfaction: Very Satisfied____, Satisfied____, Unsatisfied____, Very Unsatisfied____

Please provide any suggestions on further improving our service. Comment box

Additional comments: Comment box

May we contact you regarding your experience with this service? Yes, no

Name (Optional)

Phone Number

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Email (Optional)

Agency/Organization

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