Form 0917-0036 Wellness Center Survey

Form Approved

OMB Form No. 0917-0036

Expiration Date:

Chinle Wellness Center (CWC) – Client Satisfaction Survey

Date of Visit: _____________

Client gender: Client age: ___less than 12 years ___ 13 -17 years

__ Male ___ 18 - 24 years ___ 25 - 39 years

__ Female ___ 40 – 64 years ___ 65 and older

For each statement below circle the number based on this scale:

5 4 3 2 1

Strongly Agree

Agree

Unsure

Disagree

Strongly Disagree

1. Today, it was easy for me to get into the class and/or use the fitness equipment I wanted to use today. 5 4 3 2 1

2. At the Wellness Center, I was given support so I can take care of my own health better. 5 4 3 2 1

3. The health information given to me today was helpful. 5 4 3 2 1

4. Wellness Center staff was helpful and accessible. 5 4 3 2 1

5. The Wellness Center (equipment, restrooms, floor) was clean and in good repair during my visit today. 5 4 3 2 1

6. I am sure I can take care of my own health (T’áá hwó’ají t’éego). 5 4 3 2 1

7. Usually my health is good. 5 4 3 2 1

8. I would recommend this wellness center to my family and friends. 5 4 3 2 1

What did we do well today? ____________________________________________________________

How can we do better? We know we need a bigger facility and are working on it. Is there anything else we can improve? __________________________________________________________________

Wellness Center staff to complete this section:

__General

__Personal Training

__Fitness Assessment Staff: ________________

__New Member Orientation

__Group Fitness Class: ________

Revised 1/2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The   valid OMB control number for this information collection is 0917-0036.  The time required to complete this information collection is estimated to average 3 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.