Child Maltreatment Surveillance (Sample Web-based Assessment

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Form Approved
OMB No. 0920-XXX
Exp. Date xx/xx/20xx

Child Maltreatment Surveillance: Uniform Definitions
for Public Health
Please tell us what you think about this publication by taking a
few minutes to answer some evaluation questions. This
evaluation is voluntary. Your input is valuable and will be used to
improve future editions of this publication. Your responses are
anonymous and will be kept secure.
1

How many years experience do you have with violence
prevention?
I have no experience with violence prevention
Less than a year
1-5 years
6-10 years
11 or more years

2

This publication is useful to me in my work.
Strongly disagree

3

Neutral

Agree

Strongly agree

This publication will improve the way I work to prevent
violence.
Strongly disagree

4

Disagree

Disagree

Neutral

Agree

Strongly agree

Agree

Strongly agree

This publication is visually appealing.
Strongly disagree

Disagree

Neutral

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5

This publication is well organized.
Strongly disagree

6

Neutral

Agree

Strongly agree

I am satisfied with the quality of this publication.
Strongly disagree

7

Disagree

Disagree

Neutral

Agree

Strongly agree

I would recommend this publication to others.
Strongly disagree

Disagree

Neutral

Agree

8

What was most useful about this publication?

9

What was least useful about this publication?

Strongly agree

10 What changes would you recommend to improve this
publication to make it more effective?

Public Reporting burden of this collection of information is estimated at
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. An
agency many not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a currently valid

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OMB control number. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions
for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600
Clifton Road NE, MS D-74, Atlanta, GA 30333; Attn: PRA (0920XXXX).

Survey Page 1

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