Response Card

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

SAMPLE RESPONSE CARD

Child Maltreatment Surveillance: Uniform Definitions for Public Health

Please tell us what you think about this publication by taking a few minutes to answer some evaluation questions. This evaluation is voluntary. Your input is valuable and will be used to improve future editions of this publication. Your responses are anonymous and will be kept secure.

1. How many years experience do you have with violence prevention?

• I have no experience with violence prevention

• Less than a year

• 1-5 years

• 6-10 years

• 11 or more years

2. This publication is useful to me in my work.

• Strongly disagree

• Disagree

• Neutral

• Agree

• Strongly agree

• Neutral

3. This publication will improve the way I work to prevent violence.

• Strongly disagree

• Disagree

• Neutral

• Agree

• Strongly agree

• Neutral

4. This publication is visually appealing.

• Strongly disagree

• Disagree

• Neutral

• Agree

• Strongly agree

• Neutral

5. This publication is well organized.

• Strongly disagree

• Disagree

• Neutral

• Agree

• Strongly agree

• Neutral

6. I am satisfied with the quality of this publication.

• Strongly disagree

• Disagree

• Neutral

• Agree

• Strongly agree

• Neutral

7. I would recommend this publication to others.

• Strongly disagree

• Disagree

• Neutral

• Agree

• Strongly agree

• Neutral

8. What was most useful about this publication?

9. What was the least useful about this publication?

10. What changes would you recommend to improve this publication to make it more effective?

Public Reporting burden of this collection of information is estimated at 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency many 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-XXXX).