Client Satisfaction Survey
Today's Date
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Minutes
AM
PM
AM/PM Option
What was the date of your most recent visit?
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Month
-
Day
Year
Date
What is your Zipcode?
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What services did you request/receive from First State?
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Food Pantry
Emergency Services (rent/utility/medical bill)
After School Services
Case Management
First Time Home Buyer's Counseling
Foreclosure Counseling
Mortgage Assistance through DEMAP
Second Chance ReEntry Program
Senior Community Service Employment
Senior Companion Program
Family Support Services (PSSF)
Just seeking information
Overall, how satisfied or dissatisfied are you with First State?
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Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Neutral - Neither Satisfied or Dissatisfied
Which of the following words would you use to describe our services? (Check all that apply.)
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Reliable
Unique
High Quality
Useful
Good Value for the money
Impractical
Ineffective
Poor Quality
Unreliable
How well did our services meet your needs?
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Extremely Well
Very Well
Not So Well
Somewhat Well
Not Well At All
How would you rate the quality of our services?
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Very High Quality
Low Quality
High Quality
Very Low Quality
Neutral - Neither High nor Low Quality
How responsive have we been to your questions/concerns about our services?
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Extremely Responsive
Very Responsive
Somewhat Responsive
Not So Responsive
Not At All Responsive
Not Applicable
How long have you been a client of our Agency?
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This Was My First Visit
Less Than 6 months
Six Months To A Year
1-2 Years
3 or More Years
How likely are you to request any of our services again?
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Extremely Likely
Very Likely
Somewhat Likely
Not So Likely
Not Likely At All
How important do the employees at First State CAA make you feel?
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Extremely Important
Very Important
Moderately Important
Slightly Important
Not At All Important
How politely did our representative treat you?
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Extremely Politely
Very Politely
Moderately Politely
Slightly Politely
Not At All Politely
How likely is it that you would recommend First State CAA to a friend?
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1
2
3
4
5
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7
8
9
10
Not At All Likely
Extremely Likely
1 is Not At All Likely, 10 is Extremely Likely
Do you have any comments, questions or concerns?
Submit
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