NASS Clinic Feedback Survey

Assisted Reproductive Technology (ART) Program Reporting System

Att C4. Clinic Feedback Survey

OMB: 0920-0556

Document [pdf]
Download: pdf | pdf
Form Approved
OMB No. 0920-0556
Exp. Date xx-xx-xxxx

FEEDBACK TO CDC
ON ART DATA REPORTING
Please rate how strongly you agree or disagree with each of the following statements by clicking on the appropriate response button.
Strongly
Agree

Somewhat
Agree

Neither
Agree or
Disagree

Somewhat
Disagree

Strongly
Disagree

Not
Applicable

Click here
to unselect
a response

1.

The ART reporting system is simple to use.

O

O

O

O

O

O

O

2.

The customer service regarding ART data submission
is a useful resource.

O

O

O

O

O

O

O

3.

The time it takes to meet CDC annual reporting
requirements is acceptable.

O

O

O

O

O

O

O

4.

CDC’s ART success rates report is useful to consumers.

O

O

O

O

O

O

O

5.

CDC’s ART success rates report is useful to
professionals.

O

O

O

O

O

O

O

6.

If your ART facility was validated in the past reporting
year, the overall validation process was acceptable.

O

O

O

O

O

O

O

Thank you for providing feedback. Please feel free to add comments or suggestions in the space provided:
(Limit: ### characters)

Public reporting burden for this collection of information is estimated to average two 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 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, NE, MS D-74, Atlanta, GA 30333,
ATTN:PRA (0920-0556).


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