Form H - DxInt.CSS Form H - DxInt.CSS Form H - DxInt.CSS

OMB # 0930- XXXX

Expiration Date: xx/xx/xxxx

SAMHSA FASD Center for Excellence

Form H

Diagnosis and Intervention Programs

End of Intervention Customer Satisfaction with Service

This is a form used to determine customer satisfaction with the SAMHSA FASD Center for Excellence Diagnosis and Intervention Programs. To protect privacy, name and any other individually identifying information will not be collected. It is important to us to obtain this information to improve quality of services provided; however, participation is voluntary.

To be completed by Parent/Caregiver

Date Completed: ________ Child ID: ________

1. How satisfied are you with the services your child received after receiving the diagnosis of an FASD?

1. Satisfied

2. Somewhat Satisfied

3. No Opinion

4. Somewhat Dissatisfied

5. Dissatisfied

2. To what extent has your child’s behavior improved since receiving services for an FASD?

1. A great deal

2. Somewhat

3. No opinion

4. Not at all

3. To what extent is your child’s life better since receiving services for an FASD?

a) A lot better

b) Somewhat better

c) A little better

d) No opinion

e) Not at all better

f) Worse than before

4. How important was it to you that your child received a diagnosis of an FASD?

1. Very important

2. Somewhat important

3. No opinion

4. Not very important

5. Not at all important

Additional Comments: ___________________________________________________________

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-xxxx. Public reporting burden for this collection of information is estimated to average 2 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.

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