Administrator Survey Cover Letter

Form Approved

OMB Number: 0920-XXXX

Expiration Date: XX/XX/XXXX

2012 – 2013 SURVEY of ADMINISTRATORS OF PUBLICLY-FUNDED HEALTH CENTERS THAT PROVIDE FAMILY PLANNING SERVICES

Public reporting burden of this collection of information is estimated to average 40 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 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. 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-xxxx).

Your responses will be maintained in a secure manner. This survey has been approved by the Centers for Disease Control and Prevention as non-research public health practice.

Please answer each of the following questions as they relate to the health center where you are receiving this survey.

• If you are a part of a multi-site agency, feel free to consult with your parent agency to answer questions as needed or as may be required by your agency. However, most questions relate to this specific clinic or center (not to the parent agency).

• If you work for an agency that oversees more than one clinic or center, please answer only for the one center or clinic at which you received this survey.

• The information will not be used to assess compliance with federal or other regulations or as part of your agency’s performance reviews.

• Your complete answers are essential to helping us support publicly-funded family planning service providers in the future.

Please return this survey within 30 days using the enclosed postage paid envelope.

You may also complete the survey online (see instructions below).

To complete the survey online:

Insert Survey

ID Here

If you wish to complete the survey online, use your internet browser to go the home page at: www.<insert_website_here>.org. Only authorized users may complete the survey and your unique username and password are provided below. The web survey is conducted from a “secure” https (SSL) service using the same type of internet security as is used for handling credit card transactions. If you have any problems accessing or completing the survey, please contact [email protected].

Use this unique username and password below to access the survey:

Your username is: <username>

Your password is: <password>