Form DHS Critical Infrastructure Stakeholder Feedback

OMB Control Number:  1601-0014
Expiration Date:  XX/XX/XXXX

CLASSIFICATION: UNCLASSIFIED//FOR OFFICIAL USE ONLY

Critical Infrastructure Stakeholder
Feedback Survey
General Information
Activity, Event, or Product
Date
Please select the category that best describes your organization Select One
Private Sector
Territorial
Tribal
Local
State
Federal
Non-profit
Organization

Overall Assessment

1. Please evaluate the following statement: The information received through this activity or product was current and relevant.
Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

2. Please provide any recommendations that you may have on how future activities or products of this type could be
improved to enhance their relevance.

3. Please evaluate the following statement: The information received through this activity or product will effectively inform my decision
making regarding safety and security risk mitigation and resilience enhancements.
Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

4. Please provide any recommendations that you may have on how future activities or products of this type could be
improved to increase their value in support of your mission.

5. Please evaluate the following statement: I will encourage my agency/organization to incorporate information I learned through this activity
or product into our safety, security, or resilience practices.
Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

6. Please provide any recommendations that you may have on how future activities or products of this type could
be improved so they can be better incorporated into safety, security, or resilience practices across the critical
infrastructure community.

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Public Burden Statement

CLASSIFICATION: UNCLASSIFIED//FOR OFFICIAL USE ONLY
REV: 11 March 2014