0917-0036 Health Promotion Survey

Form Approved

OMB Form No. 0917-0036

Expiration Date:

Chinle Service Unit (CSU) Health Promotion Date: ___/__ _/_____

Customer Satisfaction Survey

Thank you for participating in one of our Health Promotion programs today. You are a valued customer and what you have to say is important to us. Please take a moment to let us know how we are doing by filling out this form and giving us your honest feedback.

Gender: Age:

 Male  Less than 18 years  35 – 64 years

 Female  18 – 34 years  65 years and older

For each statement below circle the numbers 1-5 based on this scale:

1 2 3 4 5

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

1. I would recommend the Health Promotion Program to my family and friends. - - - - - 1 2 3 4 5

2. Usually my health is good. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1 2 3 4 5

3. I am sure I can take care of my own health (T’áá hwó’ají t’éego). - - - - - - - - - - - - 1 2 3 4 5

4. The staff treated me with courtesy and respect at all times today. - - - - - - - - - - - - 1 2 3 4 5

5. The facility/event was clean and safe for all participants. - - - - - - - - - - - - - - - - 1 2 3 4 5

6. The staff worked well together and communicated effectively. - - - - - - - - - - - - - 1 2 3 4 5

What comments or suggestions do you have to improve our services, activities, and events?

___________________________________________________________________________________________

HP STAFF USE ONLY

---Injury Prevention --- CCWP ---School Health ---AV production services ---MSPI ---DVPI

HP Staff: ____________________ HP program: _______________________ HP Site: Chinle Pinon Tsaile

Revised 7/28/15

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The   valid OMB control number for this information collection is 0917-0036.  The time required to complete this information collection is estimated to average 3 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.