Recovery Month Kit

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NATIONAL ALCOHOL AND DRUG ADDICTION RECOVERY MONTH
CUSTOMER SATISFACTION FORM

We would like to know about your National Alcohol and Drug Addiction Recovery Month (Recovery Month) efforts this September and how useful you found this toolkit for planning your activities. This information will be used in the development of future outreach materials distributed by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.

Your response is voluntary, but your input is essential so that the Recovery Month materials we provide in future years will continue to meet your needs. We encourage you to include photographs and/or samples of supporting materials from your Recovery Month activities.

Download Customer Satisfaction Form as a PDF (0.3 MB)

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*First Name:

*Last Name:

*Title:

*Organization Name:

*Organization Address:

Organization Address is required

Organization Address 2:

*City:

*Select State/Country

*Zip Code:

Organization Web site address:

ex: http://www.sample.com

*Phone:

Fax:

*E-mail address:

*Please provide a brief description of your event or major activities. (Please attach additional sheets, if necessary.)

Attach file 1

Attach file 2

Attach file 3

*Did you receive media coverage?

Coverage YesNo

If yes, who covered your event? (Please attach a brief summary or copies of articles.)

Attach file 1

Attach file 2

Attach file 3

Please tell us which kit materials listed below you used and provide suggestions for improving them.

Materials	*Used It? (Y/N)	How Useful Was It?	Comments/Suggestions
Building Community Coalitions	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Planning Partners List	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Recovery Month Resources	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Single-State Agency Directory	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Promotional Event Ideas and Publicity Tips	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Media Tips	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Media Advisory	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Press Release	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Op-Ed	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Official Proclamations	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Live-Read Radio Public Service Announcements	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Letterhead	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Logo Sheet	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Overview: Real People, Real Recovery	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Commonly Misused Substances	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
A Guide to Treatment: How To Help People With Substance Use Disorders	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Join the Voices for Recovery	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Treatment Providers and the Recovery Community: People Who Change Lives	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Families: The Unsung Heroes of Recovery	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Faith-Based Organizations: How Faith Leaders Can Help People on a Path of Recovery	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Employers: How the Workforce Can Foster a Recovery Environment	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments
Civil Service Workers: How Local and State Government and Justice Personnel Can Make a Difference	Yes / No YesNo Required	How Useful? Very Useful Useful Not Useful Required	comments

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Please send your response to:

SUBSTANCE ABUSE AND MENTAL HEaltH SERVICES ADMINISTRATION
Center for Substance Abuse Treatment
Office of the Director, Consumer Affairs
1 Choke Cherry Road, Second Floor
Rockville, MD 20857
Fax: 240-276-2710 (Attn: Michele Monroe)

Thank you for sharing your Recovery Month story with us.

NOTE: Public reporting for this collection of information is estimated to average 10 minutes per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: SAMHSA Reports Clearance Officer, Paperwork Reduction Project (0930-0197); Room 5-1039, 1 Choke Cherry Road, Second Floor, Rockville, MD 20857. 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. The OMB control number for this project is 0930-0197 and the expiration date is 1/31/2011.

The Recovery Month effort aims to promote the societal benefits of alcohol and drug use disorder treatment, laud the contributions of treatment providers and promote the message that recovery from alcohol and drug use disorders in all its forms is possible.

Materials and events posted on the National Alcohol and Drug Addiction Recovery Month (Recovery Month) Web site are solely the responsibility of the authors and do not necessarily represent the official views the U.S. Department of Health and Human Services, the Substance Abuse and Mental Health Services Administration or the Center for Substance Abuse Treatment.

CSAT | CSAP | CMHS

Recovery Month Kit

NATIONAL ALCOHOL AND DRUG ADDICTION RECOVERY MONTH CUSTOMER SATISFACTION FORM

NATIONAL ALCOHOL AND DRUG ADDICTION RECOVERY MONTH
CUSTOMER SATISFACTION FORM