FormC_Client_Satis FormC_Client_Satisfaction

OMB No. 0930-0302

Expiration Date: xx/xx/xxxx

SAMHSA FASD Center for Excellence

Form C

Client Satisfaction

This form is a follow-up to the SAMHSA FASD Center for Excellence Screening and Brief Intervention or Project CHOICES program to record the level of your satisfaction with the program. To protect your privacy, your name and any other individually identifying information will not be reported to SAMHSA. It is important to us to obtain this information to maintain and improve the quality of our services; however, your participation is voluntary.

Client ID ____________________________ Agency Name ______________________________________ Date _____/_____/______ Month Day Year

All Women

Record at End of Program

1. Program completed: SBI  Project CHOICES

2. How satisfied have you been with the program?

	Very Satisfied	Satisfied	Neutral	Dissatisfied	Very Dissatisfied
How satisfied have you been with the program?	5	4	3	2	1

Comments: ____________________________________________________________________

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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 0930-0302. Public reporting burden for this collection of information is estimated to average 1 minute 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 2-1057, Rockville, Maryland, 20857.