0917-0036 Health Promotion Survey

Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys

0917-0036-Health Promotion Survey

OMB: 0917-0036

Document [docx]
Download: docx | pdf

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


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


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


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


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


  1. 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.



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitlePinon Health Center – Patient Satisfaction Survey
Authorjill.moses
File Modified0000-00-00
File Created2022-02-21

© 2024 OMB.report | Privacy Policy