6. Client Satisfaction Survey

OMB Number: 0970-0519

Expiration Date: XX/XX/XXXX

CLIENT SATISFACTION FEEDBACK

Form

In order to help the Office on Trafficking in Persons’ National Human Trafficking Training and Technical Assistance Center (NHTTAC) better serve the field, we are reaching out to obtain your feedback. We will protect the privacy of your information in accordance with the Federal Privacy Act, and we will protect the confidentiality of your responses using procedures we have in place, including reporting all information in aggregate to avoid identifying information. Only members of the NHTTAC Evaluation Team have access to information that could identify respondents. If you have any questions about this survey or the evaluation, please contact [insert].

ORGANIZATION WHERE YOU RECEIVED SERVICES DATE(S):

Please indicate the extent to which you agree or disagree with the following statements:	Strongly Disagree	Strongly Agree
The healthcare/behavioral health/human service provider [Insert topic/ competency to assess satisfaction with services #1-14].	1	8

What are the top three aspects of this visit that were most helpful and why?

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What could [Insert organization/agency] do differently to improve client/patient care in the future?

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for taking the time to complete this form and helping to improve NHTTAC activities.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to enable NHTTAC to collect recipient and stakeholder feedback to improve NHTTAC’s service delivery. The public reporting burden for this collection of information is estimated to average .083 hours per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. 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 the NHTTAC Evaluation Team at NHTTACEval@icf.com or 9300 Lee Highway, Fairfax, VA 22031.