National Center for Health Statistics (NCHS) Data Detectives Camp

Attachment G OMB No. 0920-XXXX Exp. Date XX-XX-20XX

National Center for Health Statistics

Data Detectives Summer Camp 2017

Camp Evaluation Form

NOTICE - Public reporting burden of this collection of information is estimated to average 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 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: CDC/ATSDR Information Collection Review Office; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-XXXX).

Assurance of Confidentiality - We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m(d)).

(For Students)

We would appreciate your evaluation of the Summer Camp, by completing a short questionnaire

The survey is voluntary and should take less than 10 minutes to complete. It has been designed so that no individually identifiable information will be released. Please be sure not to include any identifiable information pertaining to the survey. If you have any questions please contact us via email, at nchsfeedbacksurvey@cdc.gov .

We encourage you to complete the survey at your earliest convenience. The survey will be available online for one month, until XXXX (date will be entered here).

The findings of this survey will be used to help NCHS better serve you and the public.

We greatly appreciate your time and feedback. Thank you for providing valuable customer feedback to the National Center for Health Statistics (NCHS).

1. Overall, how would you rate your experience with the Data Detectives Camp?

   1. Excellent

   2. Very Good

   3. Average

   4. Poor

   5. Have no opinion

2. Would you recommend our program to one of your friends?

   1. Yes

   2. Not sure

   3. No

5a. If no, why not? ___________________________________________

3. What did you like best about the Camp? ____________________________________________

4. What did you like least about the Camp? ____________________________________________

5. Please share the things from your experience that you will remember, either positive or otherwise. ___________________________________________________________________

6. Anything else we should know? _____________________________________________________

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