SHIP-SMP Survey of Group Outreach and Education Events

Group Outreach and Education Survey
OMB CONTROL NUMBER: 0985-0056

The following questions ask about the presentation you recently attended. Please answer all of the questions and leave the comment card with the presenter when you finish. Thank you!

1. How did you learn about today’s presentation? (mark all that apply)

1. Event location announcement (e.g., senior center, library)

2. Mailing

3. Friend or relative

4. Another agency

5. Website

6. Previous presentation

7. TV, radio, or newspaper

8. Flyer

9. Other (please specify_______________

For questions 2 – 6, mark how much you agree or disagree with the following statement(s):	Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree
It was easy to find the details of the presentation, such as date, time, location, and topic.	A	B	C	D	E
This presentation provided me with useful information.	A	B	C	D	E
Overall, I am satisfied with the presentation today.	A	B	C	D	E
I would contact the presenter for help or information.	A	B	C	D	E
I would recommend this presentation to others.	A	B	C	D	E

7. Based on what you learned today, do you plan to take any specific actions?

1. Yes (please specify below).

__________________________________________________________________________________

2. No.

3. Don’t know/not sure.

8. What could we do to improve the information or service(s) provided to you today?

Presentation information to be completed by program official.		Location:
Time:	Date:
Name of Presenter: ___________	________________________	Address:
Office of Management and Budget (OMB) Survey Expiration Date: xx xx, xxxx

PRA Public Burden Statement:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number (OMB 0985-0056).  Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for gathering and maintaining the data needed and completing and reviewing the collection of information.  The obligation to respond to this collection is voluntary. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Administration for Community Living, U.S. Department of Health and Human Services, 330 C Street, SW, Washington, DC 20201-0008, Attention Sara Vogler, or [email protected].