Administrator/Clinician Feedback Forms

CDC Assessment of Cancer Prevention Services At CMHCs

P sychiatric Clinician Survey Pilot

FEEDBACK FORM

1. Were there questions that you did not understand?

 Yes

 No

1.a. If yes, which questions were unclear?

1.b. What about the questions was unclear?

2. Were there questions that you were unable to answer, even though you understood them?

 Yes

 No

2.a. If yes, please list the question numbers or topics.

2.b. Why were you unable to answer the question (s)?

3. How much time, if any, did you spend searching for the materials you needed to answer the survey questions?

4. Approximately how long did it take you to complete the survey? (In minutes)

5. If you completed the survey in more than one sitting, were you able to easily save your responses and get back into the survey?

 Yes

 No

6.a. If no, what problems did you experience?

7. What other comments do you have about the survey?

May we contact you if we have other questions?

 Yes

 No

YOUR FEEDBACK IS GREATLY APPRECIATED

CDC Assessment of Cancer Prevention Services At CMHCs

A dministrator Survey Pilot

FEEDBACK FORM

1. Were there questions that you did not understand?

 Yes

 No

1.a. If yes, which questions were unclear?

1.b. What about the questions was unclear?

2. Were there questions that you were unable to answer, even though you understood them?

 Yes

 No

2.a. If yes, please list the question numbers or topics.

2.b. Why were you unable to answer the question (s)?

3. How much time, if any, did you spend searching for the materials you needed to answer the survey questions?

4. Approximately how long did it take you to complete the survey? (In minutes)

5. If you completed the survey in more than one sitting, were you able to easily save your responses and get back into the survey?

 Yes

 No

6.a. If no, what problems did you experience?

7. What other comments do you have about the survey?

May we contact you if we have other questions?

 Yes

 No

YOUR FEEDBACK IS GREATLY APPRECIATED