Recovery Month 2013 - Customer Satisfaction Form

Download the PDF version of "Customer Satisfaction Form" (1.43 MB).

We would like to know about your National Recovery Month (Recovery Month) efforts this September and how useful you found this toolkit for planning your activities. This information will be used in the development of future outreach materials distributed by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT).

We would like to know about your efforts this September and how useful you found this toolkit for planning your activities. This information will be used in the development of future outreach materials distributed by the , , .

Your response is voluntary, but your input is essential so that the Recovery Month materials we provide in future years will continue to meet your needs. We encourage you to include photographs and/or samples of supporting materials from your Recovery Month activities.

* indicates a required field.

NOTE: Public reporting for this collection of information is estimated to average 10 minutes per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: SAMHSA Reports Clearance Officer, Paperwork Reduction Project (0930-0197); Room 5-1039, 1 Choke Cherry Road, Second Floor, Rockville, MD 20857. 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. The OMB control number for this project is 0930-0197 and the expiration date is 3/31/2014.

Please provide a brief description of your event or major activities. (Please attach additional sheets, if necessary.):

Attach Brief Description:

Did you receive media coverage?:	Did you receive media coverage? YesNo

If yes, who covered your event? (Please attach a brief summary or copies of articles.):

Attach Brief Summary:

Printed Materials	Used It?	How Useful Was It?	Comments/Suggestions
Fast Facts About Health Reform, Substance Use and Mental Disorders, Treatment, and Recovery	Used fast facts? YesNo	How useful were fast facts? Very Useful Useful Not Useful	Comments
Developing Your Social Network	Used developing your social network? YesNo	How useful was developing your social network? Very Useful Useful Not Useful	Comments
Building Community Coalitions	Used was building community coalitions? YesNo	How useful was building community coalitions? Very Useful Useful Not Useful	Comments
Planning Partners Directory	Used planning partners directory? YesNo	How useful was planning partners directory? Very Useful Useful Not Useful	Comments
Single-State Agency Directory	Used Single-State Agency Directory? YesNo	How useful Single-State Agency Directory? Very Useful Useful Not Useful	Comments
Prevention, Treatment, and Recovery Resources	Used Prevention, Treatment, and Recovery Resources? YesNo	How useful was Prevention, Treatment, and Recovery? Very Useful Useful Not Useful	Comments
Targeted Outreach Booklet	Used targeted outreach booklet? YesNo	How useful was targeted outreach booklet? Very Useful Useful Not Useful	Comments
Commonly Misused Substances Booklet	Used Commonly Misused Substances Booklet? YesNo	How useful was Commonly Misused Substances Booklet? Very Useful Useful Not Useful	Comments
*Join the Voices for Recovery* Mini-Book	Used Voices Mini-Book? YesNo	How useful was Voices Mini-Book? Very Useful Useful Not Useful	Comments

Online Materials	Used It?	How Useful Was It?	Comments/Suggestions
Promoting *Recovery Month* With Events	Used promoting recovery month with events? YesNo	How useful was promoting recovery month with events? Very Useful Useful Not Useful	Comments
Working With the Media	Used working with the media? YesNo	How useful was working with the media? Very Useful Useful Not Useful	Comments
Press Materials for Your *Recovery Month Event*	Used press materials? YesNo	How useful were press materials? Very Useful Useful Not Useful	Comments
Writing an Op-ed During *Recovery Month*	Used writing an op-ed? YesNo	How useful was writing an op-ed? Very Useful Useful Not Useful	Comments
Official *Recovery Month* Proclamations	Used official proclamations? YesNo	How useful was official proclamations? Very Useful Useful Not Useful	Comments
Using PSAs to Promote *Recovery Month*	Used using PSAs to promote recovery month? YesNo	How useful was using PSAs to promote recovery month? Very Useful Useful Not Useful	Comments
Banners, Letterhead, and Logos	Used Banners, Letterhead, and Logos? YesNo	How useful was Banners, Letterhead, and Logos? Very Useful Useful Not Useful	Comments
Overview: Recovery Benefits Everyone!	Used Overview: Recovery Benefits Everyone? YesNo	How useful was Recovery Benefits Everyone? Very Useful Useful Not Useful	Comments
A Policymaker’s Guide for Combating Substance Use and Mental Disorders	Used policymaker's guide? YesNo	How useful was policymaker's guide? Very Useful Useful Not Useful	Comments
Substance Use and Mental Disorders Affect All Individuals	Used Substance Use and Mental Disorders Affect All Individuals? YesNo	How useful was Substance Use and Mental Disorders Affect All Individuals? Very Useful Useful Not Useful	Comments
Health Care Providers’ Role in Addressing Substance Use and Mental Disorders	Used Health Care Providers' Role? YesNo	How useful was Health Care Providers' Role? Very Useful Useful Not Useful	Comments
Addressing Substance Use and Mental Disorders in the Workplace	Used Substance Use and Mental Disorders in the Workplace? YesNo	How useful was Substance Use and Mental Disorders in the Workplace? Very Useful Useful Not Useful	Comments
Treatment and Recovery: Finding Personalized Help	Used treatment and recovery? YesNo	How useful was treatment and recovery? Very Useful Useful Not Useful	Comments
Commonly Misused Substances	Used Commonly Misused Substances? YesNo	How useful was Commonly Misused Substances? Very Useful Useful Not Useful	Comments
New Media Glossary	Used New Media Glossary? YesNo	How useful was New Media Glossary? Very Useful Useful Not Useful	Comments

Substance Abuse & Mental Health Services Administration

2012 Toolkit

Customer Satisfaction Form