0920-0729 Att F Parent Eval Form

Attachment F OMB No. 0920-0729 Exp. Date 05/31/2017

National Center for Health Statistics

Data Detectives Summer Camp 2016

Camp Evaluation Form

Notice-Public reporting burden for this collection of information is estimated to average 10 minutes per response, including 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 current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to: CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0234).

Assurance of confidentiality-All information which would permit identification of an individual, a practice, or an establishment will be held confidential; will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls; and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

(For Parents)

We would appreciate your evaluation of the Summer Camp, by completing a short questionnaire

The survey is voluntary and should take less than 10 minutes to complete. It has been designed so that no individually identifiable information will be released. Please be sure not to include any identifiable information pertaining to the survey. If you have any questions please contact us via email, at nchsfeedbacksurvey@cdc.gov .

We encourage you to complete the survey at your earliest convenience. The survey will be available online for one month, until XXXX (date will be entered here).

The findings of this survey will be used to help NCHS better serve you and the public.

We greatly appreciate your time and feedback. Thank you for providing valuable customer feedback to the National Center for Health Statistics (NCHS).

1. Overall, how would you rate your experience with the Data Detectives Camp?

   1. Excellent

   2. Very Good

   3. Average

   4. Poor

   5. Have no opinion

2. How was your registration experience?

   1. Excellent

   2. Very Good

   3. Average

   4. Poor

   5. Have no opinion

2a. Tell us more about your registration experience: _______________________

3. How was your child's experience here?

   1. Excellent

   2. Very Good

   3. Average

   4. Poor

   5. Have no opinion

3a. Tell us more about your child's experience here: _________________________

4. How did our staff do?

   1. Excellent

   2. Very Good

   3. Average

   4. Poor

   5. Have no opinion

4a. How could our staff do better? ______________________________

5. Would you recommend our program to another family?

   1. Yes

   2. Not sure

   3. No

5a. If no, why not? ___________________________________________

6. Please share the things from your experience that you and/or your child will remember, either positive or otherwise. ___________________________________________________________________

Anything else we should know? _____________________________________________________

2