Form A-11 (Aggregate) A-11 (Aggregate) UAC Satisfaction Survey Aggregate Data

OMB 0970-#### [valid through MM/DD/20YY]

Office of Refugee Resettlement

UAC Satisfaction Survey Aggregate Data

Care Provider Provider Name:

Enter provider name here.

Fiscal Year:

Enter fiscal year here.

1. Did you like living at this shelter?

2. Did you feel safe during your time at this shelter?

3. Do you feel prepared to live outside this shelter with your sponsor?

Quarter

Yes, very much

Mostly

It was okay

Not much

Not at all

I felt very safe

I felt safe most of the time

I felt safe sometimes

I felt unsafe

I felt very unsafe

I am very prepared

I am mostly prepared

I'm a little prepared

I'm a little unprepared

I'm not prepared at all

Q1

Q2

Q3

Q4

Annual Total

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: This information collection allows ORR care providers to provide aggregate data from UAC Satisfaction Survey forms for trend analysis and improvment of service provision. Public reporting burden for this collection of information is estimated to average 4 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (8 U.S.C. § 1232). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information please contact infocollection@acf.hhs.gov.