Form 4 Smoking Cessation Clients Demographic & Customer Satisfa

NCI/Office of Communications and Public Liaison

APPENDIX 9

Customer Satisfaction Survey

OMB NO: 0925-0208
EXPIRATION DATE: 04/30/2019

Collection of this information is authorized by the Public Health Service Act, Section 411 (42 USC 285a).  Rights of study participants are protected by the Privacy Act of 1974.  Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time.  Refusal to participate will not affect your benefits in any way.  The information collected in this study will be kept private, under the Privacy Act.  Names and other identifiers will not appear in any report of this study.  Information provided will be combined for all study participants and reported as summaries.  You are being contacted by email to complete this instrument so that we can assess client satisfaction with services provided by the National Cancer Institute's Cancer Information Service.  

Public reporting burden for this collection of information is estimated to average 2 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 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0046-17). Do not return the completed form to this address.

--------------------------------------------------------------------------------

Thank you for contacting the National Cancer Institute. The following questions help us assess how satisfied you were with the service you received. Your responses are anonymous. Thank you in advance for answering these questions so that we may better serve the public.

Using a scale from 1-10, where 1 means Extremely Dissatisfied and 10 means Extremely Satisfied, how satisfied are you with the assistance you received?

1- Extremely Dissatisfied

2

3

4

5

6

7

8

9

10-Extremely Satisfied

Using a scale from 1-10, where 1 means Extremely Unlikely and 10 means Extremely Likely, how likely are you to contact our service again in the future?

1 -Extremely Unlikely

2

3

4

5

6

7

8

9

10 - Extremely Likely

Are there any comments you would like to leave about the service you received? 

Submit

English Phones: https://livehelp.cancer.gov/ci/documents/detail/5/10/12/5d10149b08f9281165f65760271ae91ffa627625

Spanish Phones: https://livehelp.cancer.gov/ci/documents/detail/5/12/12/08f3b330913c1277dfc1885abd899143cd02bfff

English Email: https://livehelp.cancer.gov/ci/documents/detail/5/8/12/45ca9f62c58ab15b9fe123a36b3a420c68eccd66

Spanish Email: https://livehelp.cancer.gov/ci/documents/detail/5/11/12/245cfe1718889dd43ee26d6654e354af8331c668

English LH: https://livehelp.cancer.gov/ci/documents/detail/5/9/12/99f9b0c9af441a03b923f1e3fdd02d88cc0c3a92

Spanish LH: https://livehelp.cancer.gov/ci/documents/detail/5/15/12/46a3781bc6dfdc82f309c8bc39687b788ca573b1

VA Phones: https://livehelp.cancer.gov/ci/documents/detail/5/16/12/cd491660ec409154660288733c9e7e9b364c1a63

VA LH: https://livehelp.cancer.gov/ci/documents/detail/5/17/12/c2b1a2d2b4d242261ce77edecc37034fb7b99485