CSAT BASELINE MEETING SATISFACTION SURVEY
 

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Form Approved 

OMB NO. 0930-0197 

Exp. Date 01/31/2014 

Public reporting burden for this collection of information is 

estimated to average 10 minutes per response to complete the 

Contact Information Form and this questionnaire. Send comments 

regarding this burden estimate or any other aspect of this collection 

of information to the SAMHSA Reports Clearance Officer, 

Room 7-1045, 1 Choke Cherry Road, Rockville, MD 20850. An CENTER FOR SUBSTANCE ABUSE TREATMENT 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. The control number for this project is 

0930-0197. 

Customer Survey—CSAT Meeting 

Please enter the Personal ID Code you used on the consent form here _____________. 

Date of meeting, location (i.e., city, state), and topic will be pre-coded and entered in this area of the form.
 

Please check here ( ) if you have received this survey in error, (i.e., you did not attend the meeting listed 

above) and return the uncompleted survey in the enclosed postage-paid envelope. 

PLEASE BASE YOUR ANSWER ON HOW YOU FEEL ABOUT 

THE SESSION NOW. 

Very Very 

Satisfied Satisfied Neutral Dissatisfied Dissatisfied 

1. How satisfied are you with the overall quality of this meeting? 1 2 3 4 5 

2. How satisfied are you with the quality of the 1 2 3 4 5 

information/instruction from this meeting? 

3. How satisfied are you with the quality of the meeting 1 2 3 4 5 

materials? 

4. Overall, how satisfied are you with the meeting experience? 1 2 3 4 5 

PLEASE INDICATE YOUR AGREEMENT WITH THESE 

STATEMENTS ABOUT THE MEETING. 

Strongly Strongly 

Agree Agree Neutral Disagree Disagree 

5. The meeting class was well organized. 1 2 3 4 5 

6. The material presented in this meeting class will be useful to 1 2 3 4 5 

me in dealing with substance abuse. 

7. I expect to use the information gained from this meeting. 1 2 3 4 5 

8. I expect this meeting to benefit my clients. 1 2 3 4 5 

9. This meeting was relevant to substance abuse treatment. 1 2 3 4 5 

10. I would recommend this meeting to a colleague. 1 2 3 4 5 

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Very Not 

Useful Useful Neutral Useless Applicable 

11. How useful was the information you received? 1 2 3 4 5 

12. Please indicate which title best describes your job: 

___Medical Director ___Clinical Administrator/Manager ___Federal Government Official 

___Physician ___Clinical Supervisor ___State Government Official 

___Nurse ___Psychologist ___County Government Official 

___Physician's Assistant ___Counselor ___Researcher 

___Pharmacist ___Social Worker ___Other (please specify)____________ 

___Manager/Director 

13. Please indicate which best describes your agency or affiliation: 

___Federal Government ___Substance Abuse Treatment Program 

___State Government ___University or other higher education institution 

___County Government ___Other (please describe)_________________________________ 

___Local Government 

14. What is your gender? 1.____Male 2.____Female 

15. Are you Hispanic or Latino? 1.____Yes 2.____No 

16. What is your race (Mark all that apply)? 

____Black or African American ____Alaska Native 

____Asian ____American Indian 

____White ____Native Hawaiian or Other Pacific Islander 

What about the meeting was most useful in supporting your work responsibilities? 

How can we improve our meetings? 

Thank you for completing our survey. 

Return your survey to the Survey Administrator for your Session. 

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