example of surveys

Example of Customer Survey

OMB No. 0915-0212

Exp. Date: 04/30/2009

New Freedom Initiative Caregiver Broadcast Survey

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 0915-0212. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, 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: HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

1. How did you first learn about the broadcast?

From a work colleague

From a friend or relative

At a meeting or conference

From the radio, newspaper or magazine

From an e-mail, liseserv or website

Other

2. What is your background or place of employment?

I am a caregiver (paid)

I am a caregiver (unpaid)

I work for a state or local government

I work for a Federal agency

I work for a non-profit

Tribe or Tribal organization

Other

3. Has the NFI broadcast increased your knowledge and awareness about caregiving issues?

(5=maximum knowledge and awareness, 1=no knowledge or awareness gained)

5

4

3

2

1

4. Overall, I think the broadcast was:

Very interesting and informative

Somewhat interesting and informative

Not at all interesting and informative

5. Please rate the broadcast: how useful was it to you?

(5=very useful, 1=not useful)

5

4

3

2

1

6. What topics would you like to see in future broadcasts? (check all that apply)

Serving Rural Caregivers

Reaching Out To Culturally Diverse Communities

Young Caregivers

Health Implications of Caregiving on the Caregiver

Disaster Education and Planning For Caregivers

How To Reach Caregivers That May Not Be In the System or May Not Know They Are Caregivers

Integrating Volunteers into the Systems of Care

Expanding Caregiver related Programs in An Era of Flat Budgets

Other topics:

7. I thought the broadcast (check all that apply):

Should have included more time for presentations

Should have included less time for presentations

Should have included more time for Questions & Answers

Should have included less time for Questions & Answers
Lasted about the right length of time
Lasted too long

8. Did you like the format of the broadcast?

Yes

No

Unsure or undecided

9. In what ways could the format of the broadcast be improved, please explain:

10. What do you suggest to improve future broadcasts?